Healthcare Provider Details

I. General information

NPI: 1194182535
Provider Name (Legal Business Name): CHILDREN'S DENTAL CARE OF CANTON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2016
Last Update Date: 01/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5867 N LILLEY RD
CANTON MI
48187-3623
US

IV. Provider business mailing address

5867 N LILLEY RD
CANTON MI
48187-3623
US

V. Phone/Fax

Practice location:
  • Phone: 313-404-1061
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number2901019369
License Number StateMI

VIII. Authorized Official

Name: DR. HASSAN S OUEIS
Title or Position: PRESIDENT
Credential: DDS
Phone: 313-404-1061