Healthcare Provider Details

I. General information

NPI: 1639544265
Provider Name (Legal Business Name): AZIZ MOUKLED
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2015
Last Update Date: 01/23/2023
Certification Date: 01/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 MARTIN LUTHER KING JR BLVD
DETROIT MI
48208-2576
US

IV. Provider business mailing address

149 MARTIN DRIVE
BELLE RIVER ON
N0R1A0
CA

V. Phone/Fax

Practice location:
  • Phone: 313-494-6700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number2901021724
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2952000814
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: