Healthcare Provider Details

I. General information

NPI: 1790216315
Provider Name (Legal Business Name): DINA ELHOUT DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2017
Last Update Date: 03/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 N TELEGRAPH RD
DEARBORN MI
48128-1619
US

IV. Provider business mailing address

430 N TELEGRAPH RD
DEARBORN MI
48128-1619
US

V. Phone/Fax

Practice location:
  • Phone: 313-563-6601
  • Fax: 313-563-6986
Mailing address:
  • Phone: 313-563-6601
  • Fax: 313-563-6986

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number2901021238
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number2901021098
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number2901020729
License Number StateMI

VIII. Authorized Official

Name: YASSER ALALI
Title or Position: DENTIST/OWNER
Credential: DDS
Phone: 313-563-6601