Provider Demographics
NPI:1669965257
Name:METWALLY, TAREK NABIL
Entity type:Individual
Prefix:
First Name:TAREK
Middle Name:NABIL
Last Name:METWALLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42051 MOUND RD
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48314-3143
Mailing Address - Country:US
Mailing Address - Phone:586-323-7700
Mailing Address - Fax:
Practice Address - Street 1:22180 PONTIAC TRL STE A
Practice Address - Street 2:
Practice Address - City:SOUTH LYON
Practice Address - State:MI
Practice Address - Zip Code:48178-9097
Practice Address - Country:US
Practice Address - Phone:248-486-9202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-08
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010225831223S0112X, 390200000X, 1223S0112X
MI4351048738390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program