Provider Demographics
NPI:1821730920
Name:WIXOM DENTAL
Entity Type:Organization
Organization Name:WIXOM DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:HUSSEIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:248-859-5300
Mailing Address - Street 1:49175 PONTIAC TRL
Mailing Address - Street 2:
Mailing Address - City:WIXOM
Mailing Address - State:MI
Mailing Address - Zip Code:48393-2580
Mailing Address - Country:US
Mailing Address - Phone:248-859-5300
Mailing Address - Fax:
Practice Address - Street 1:49175 PONTIAC TRL
Practice Address - Street 2:
Practice Address - City:WIXOM
Practice Address - State:MI
Practice Address - Zip Code:48393-2580
Practice Address - Country:US
Practice Address - Phone:248-859-5300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-08
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental