Provider Demographics
NPI:1750597894
Name:ADVANCE DENTAL GROUP P.C.
Entity type:Organization
Organization Name:ADVANCE DENTAL GROUP P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:ABRAHAM
Authorized Official - Middle Name:L
Authorized Official - Last Name:AZZOUZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:248-442-2273
Mailing Address - Street 1:33466 W 8 MILE RD
Mailing Address - Street 2:SUITE333
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48335-5208
Mailing Address - Country:US
Mailing Address - Phone:248-442-2273
Mailing Address - Fax:242-442-9499
Practice Address - Street 1:33466 W 8 MILE RD
Practice Address - Street 2:SUITE333
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48335-5208
Practice Address - Country:US
Practice Address - Phone:248-442-2273
Practice Address - Fax:242-442-9499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010156751223G0001X
124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Not Answered124Q00000XDental ProvidersDental HygienistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MID15675OtherBCBS