Provider Demographics
NPI:1336203256
Name:AZIZ, BALSAM (DDS)
Entity Type:Individual
Prefix:DR
First Name:BALSAM
Middle Name:
Last Name:AZIZ
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:BALSAM
Other - Middle Name:
Other - Last Name:AZIZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:2141 15 MILE RD
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48310-4807
Mailing Address - Country:US
Mailing Address - Phone:586-795-5504
Mailing Address - Fax:
Practice Address - Street 1:2141 15 MILE RD
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48310-4807
Practice Address - Country:US
Practice Address - Phone:586-795-5504
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI15277122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI383223640OtherALL OTHER INSURANCES
MI4927253Medicaid