Healthcare Provider Details

I. General information

NPI: 1770322018
Provider Name (Legal Business Name): EMAN BASHIR. A KHALIL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2024
Last Update Date: 08/25/2024
Certification Date: 08/25/2024
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

2920 NORMANDY
WINDSOR ZZ - FOREIGN COUNTRIES
N9H 2P2
CA

V. Phone/Fax

Practice location:
  • Phone: 313-494-6615
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number27783
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number2952000851
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: