Healthcare Provider Details

I. General information

NPI: 1942861612
Provider Name (Legal Business Name): MIKAELA KOFMAN DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2019
Last Update Date: 08/23/2021
Certification Date: 08/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 SAINT ANTOINE ST
DETROIT MI
48201-2153
US

IV. Provider business mailing address

3150 WOODWARD AVE APT 402
DETROIT MI
48201-2750
US

V. Phone/Fax

Practice location:
  • Phone: 313-745-4697
  • Fax:
Mailing address:
  • Phone: 416-697-2998
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number1741998
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2901600522
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: