Healthcare Provider Details

I. General information

NPI: 1780508010
Provider Name (Legal Business Name): FATIMA EDRISS DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2026
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3932 CHARLES ST
DEARBORN MI
48126-3425
US

IV. Provider business mailing address

3932 CHARLES ST
DEARBORN MI
48126-3425
US

V. Phone/Fax

Practice location:
  • Phone: 313-415-1175
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901603275
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: