Healthcare Provider Details

I. General information

NPI: 1306407234
Provider Name (Legal Business Name): GORGINA A MAKRAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2019
Last Update Date: 06/20/2026
Certification Date: 06/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7222 EDWARD
CENTER LINE MI
48015-1007
US

IV. Provider business mailing address

7222 EDWARD
CENTER LINE MI
48015-1007
US

V. Phone/Fax

Practice location:
  • Phone: 248-525-7790
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901603174
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: