Healthcare Provider Details

I. General information

NPI: 1194323303
Provider Name (Legal Business Name): AQ DENTAL GROUP PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2020
Last Update Date: 10/12/2020
Certification Date: 10/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10413 FORD ROAD, UNITS M & N
DEARBORN MI
48126
US

IV. Provider business mailing address

6402 JONATHON ST
DEARBORN MI
48126-2230
US

V. Phone/Fax

Practice location:
  • Phone: 313-826-2138
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ABDULJALIL AL-HAJJAJ
Title or Position: DENTIST
Credential: DDS
Phone: 313-826-2138