Healthcare Provider Details

I. General information

NPI: 1710945308
Provider Name (Legal Business Name): ABRAHAM LAWRENCE AZZOUZ D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24366 GRAND RIVER AVE SUITE 111
DETROIT MI
48219-3063
US

IV. Provider business mailing address

24366 GRAND RIVER AVE SUITE 111
DETROIT MI
48219-3063
US

V. Phone/Fax

Practice location:
  • Phone: 313-535-2273
  • Fax: 313-535-5212
Mailing address:
  • Phone: 313-535-2273
  • Fax: 313-535-5212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901015675
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2902014138
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: