Healthcare Provider Details

I. General information

NPI: 1104482439
Provider Name (Legal Business Name): CHILDRENS DENTAL CARE OF DETROIT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2019
Last Update Date: 01/05/2021
Certification Date: 01/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 MACK AVE
DETROIT MI
48201-2136
US

IV. Provider business mailing address

430 MACK AVE
DETROIT MI
48201-2136
US

V. Phone/Fax

Practice location:
  • Phone: 313-262-6059
  • Fax: 313-262-6331
Mailing address:
  • Phone: 313-262-6059
  • Fax: 313-262-6331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: HASSAN OUEIS
Title or Position: OWNER
Credential: DDS
Phone: 313-262-6059