Healthcare Provider Details

I. General information

NPI: 1952984957
Provider Name (Legal Business Name): MICHAEL WEISS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2021
Last Update Date: 03/09/2023
Certification Date: 03/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

623 COURTHOUSE DR
CHARLOTTE MI
48813-1072
US

IV. Provider business mailing address

25055 PIERCE ST
SOUTHFIELD MI
48075-2017
US

V. Phone/Fax

Practice location:
  • Phone: 517-541-8157
  • Fax:
Mailing address:
  • Phone: 732-619-8756
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901601244
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: