Healthcare Provider Details

I. General information

NPI: 1750071536
Provider Name (Legal Business Name): GHENA LEBBOS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2023
Last Update Date: 06/27/2026
Certification Date: 06/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25031 ROUGE RIVER DR
DEARBORN HEIGHTS MI
48127-1730
US

IV. Provider business mailing address

25031 ROUGE RIVER DR
DEARBORN HTS MI
48127-1730
US

V. Phone/Fax

Practice location:
  • Phone: 313-467-2907
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901603083
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: