Provider Demographics
NPI:1811476955
Name:LIVONIA LASER DENTISTRY
Entity type:Organization
Organization Name:LIVONIA LASER DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMIN
Authorized Official - Prefix:MR
Authorized Official - First Name:FADY
Authorized Official - Middle Name:
Authorized Official - Last Name:MANSOUR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-425-6920
Mailing Address - Street 1:31632 SCHOOLCRAFT RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-1819
Mailing Address - Country:US
Mailing Address - Phone:734-425-6920
Mailing Address - Fax:734-425-1541
Practice Address - Street 1:31632 SCHOOLCRAFT RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48150-1819
Practice Address - Country:US
Practice Address - Phone:734-425-6920
Practice Address - Fax:734-425-1541
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-09
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010170251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2901017025OtherMICHIGAN PROFESSIONAL LICENSE - DENTISY
MI13167481Medicaid