MEDICARE: ALL STAR KIDS PEDIATRIC DENTISTRY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1285490441
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALL STAR KIDS PEDIATRIC DENTISTRY

Provider Business Mailing Address
First Line	:	1849 N DENWOOD ST
Second Line	:
City	:	DEARBORN
State	:	MI
Zip	:	48128-1156
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4925 S TELEGRAPH RD
Second Line	:
City	:	DEARBORN HEIGHTS
State	:	MI
Zip	:	48125-2027
Country	:	US
Telephone Number	:	313-254-0777
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MOHAMMED SOBH
Credential	:	DDS
Telephone Number	:	313-663-6484

Provider Enumeration Date	:	02/26/2024
Last Update Date	:	05/23/2024

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