Healthcare Provider Details

I. General information

NPI: 1972653244
Provider Name (Legal Business Name): SAMAR MOKHAYESH DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30060 23 MILE RD
CHESTERFIELD MI
48047-5718
US

IV. Provider business mailing address

52833 SEVEN OAKS DR
SHELBY TOWNSHIP MI
48316-2992
US

V. Phone/Fax

Practice location:
  • Phone: 586-949-2240
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number28901017682
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: