Healthcare Provider Details

I. General information

NPI: 1891831632
Provider Name (Legal Business Name): GEORGE ZIYADEH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11180 GRATIOT AVE
DETROIT MI
48213-1363
US

IV. Provider business mailing address

11180 GRATIOT AVE
DETROIT MI
48213-1363
US

V. Phone/Fax

Practice location:
  • Phone: 313-245-1780
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901016510
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: