Provider Demographics
NPI:1821185539
Name:KEJBOU, DANI S (DDS)
Entity Type:Individual
Prefix:MR
First Name:DANI
Middle Name:S
Last Name:KEJBOU
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:491 MYSTIC VALLEY
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48307
Mailing Address - Country:US
Mailing Address - Phone:248-608-0877
Mailing Address - Fax:
Practice Address - Street 1:50 W BIG BEAVER RD
Practice Address - Street 2:SUITE 100A
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48304
Practice Address - Country:US
Practice Address - Phone:248-290-2900
Practice Address - Fax:248-290-2904
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI18890122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1956314870OtherBCBS OF MI
1811506OtherUNITED CONCORDIA
MI4852546Medicaid