Healthcare Provider Details

I. General information

NPI: 1770036477
Provider Name (Legal Business Name): CHILDRENS MOBILE DENTAL CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2016
Last Update Date: 07/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14710 W WARREN AVE
DEARBORN MI
48126-1347
US

IV. Provider business mailing address

14710 W WARREN AVE
DEARBORN MI
48126-1347
US

V. Phone/Fax

Practice location:
  • Phone: 313-404-1061
  • Fax:
Mailing address:
  • Phone: 313-404-1061
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number19369
License Number StateMI

VIII. Authorized Official

Name: HASSAN OUEIS
Title or Position: PRESIDENT
Credential: DDS
Phone: 313-404-1061