MEDICARE: DEARBORN FAMILY DENTAL LLC

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	:	1770266843
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEARBORN FAMILY DENTAL LLC

Provider Business Mailing Address
First Line	:	24521 FORD RD
Second Line	:
City	:	DEARBORN
State	:	MI
Zip	:	48128-1131
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	24521 FORD RD
Second Line	:
City	:	DEARBORN
State	:	MI
Zip	:	48128-1131
Country	:	US
Telephone Number	:	313-278-6333
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. BASMA A BERRY
Credential	:	DMD
Telephone Number	:	313-574-8337

Provider Enumeration Date	:	08/07/2023
Last Update Date	:	08/07/2023

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