Healthcare Provider Details

I. General information

NPI: 1487858585
Provider Name (Legal Business Name): LUIS LITONJUA DMD, DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2007
Last Update Date: 07/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 MARTIN LUTHER KING JR BLVD DEPT. OF PERIODONTICS
DETROIT MI
48208-2576
US

IV. Provider business mailing address

28900 LANCASTER ST APT. 48
LIVONIA MI
48154-3861
US

V. Phone/Fax

Practice location:
  • Phone: 313-494-6660
  • Fax:
Mailing address:
  • Phone: 734-765-7525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number2901019487
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: