Provider Demographics
NPI:1770266843
Name:DEARBORN FAMILY DENTAL LLC
Entity type:Organization
Organization Name:DEARBORN FAMILY DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BASMA
Authorized Official - Middle Name:A
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:313-574-8337
Mailing Address - Street 1:24521 FORD RD
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48128-1131
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24521 FORD RD
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48128-1131
Practice Address - Country:US
Practice Address - Phone:313-278-6333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-07
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental