Healthcare Provider Details

I. General information

NPI: 1639085277
Provider Name (Legal Business Name): IMMACULATE DENTAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2026
Last Update Date: 08/22/2026
Certification Date: 08/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4060 HAGGERTY RD
COMMERCE TOWNSHIP MI
48390-1313
US

IV. Provider business mailing address

34078 GLOUSTER CIR
FARMINGTON HILLS MI
48331-4700
US

V. Phone/Fax

Practice location:
  • Phone: 248-363-0480
  • Fax:
Mailing address:
  • Phone: 248-312-8255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. LEENA ATISHA
Title or Position: SOLE MEMBER
Credential: DDS
Phone: 248-312-8255