Provider Demographics
NPI:1750973525
Name:LOUIE, KE'ALE W
Entity type:Individual
Prefix:
First Name:KE'ALE
Middle Name:W
Last Name:LOUIE
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 1:1741 COBURN CT
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-8902
Mailing Address - Country:US
Mailing Address - Phone:818-917-8986
Mailing Address - Fax:
Practice Address - Street 1:3060 BAKER RD
Practice Address - Street 2:
Practice Address - City:DEXTER
Practice Address - State:MI
Practice Address - Zip Code:48130-1140
Practice Address - Country:US
Practice Address - Phone:734-426-4651
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-03
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29016007931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice