Provider Demographics
NPI:1649013855
Name:ALATASSI, JALA (DDS)
Entity type:Individual
Prefix:MRS
First Name:JALA
Middle Name:
Last Name:ALATASSI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5425 LONGMEADOW RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48304-3663
Mailing Address - Country:US
Mailing Address - Phone:248-930-0603
Mailing Address - Fax:248-930-0603
Practice Address - Street 1:4139 BALDWIN RD
Practice Address - Street 2:
Practice Address - City:AUBURN HILLS
Practice Address - State:MI
Practice Address - Zip Code:48326-1225
Practice Address - Country:US
Practice Address - Phone:248-630-7900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-15
Last Update Date:2024-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901602159APP241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice