Healthcare Provider Details

I. General information

NPI: 1225115884
Provider Name (Legal Business Name): DOUGLAS F DZIUBA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25923 WEST WARREN
DEARBORN HEIGHTS MI
48127
US

IV. Provider business mailing address

51111 PLYMOUTH RIDGE DR
PLYMOUTH TOWNSHIP MI
48170
US

V. Phone/Fax

Practice location:
  • Phone: 313-561-3372
  • Fax: 313-561-0817
Mailing address:
  • Phone: 739-454-7268
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number10960
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: