Healthcare Provider Details

I. General information

NPI: 1003459355
Provider Name (Legal Business Name): NASER MOHAMMADZADEH REZAEI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2019
Last Update Date: 05/31/2026
Certification Date: 05/31/2026
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

2420 BAGLEY ST UNIT 219
DETROIT MI
48216-1986
US

V. Phone/Fax

Practice location:
  • Phone: 313-494-6700
  • Fax:
Mailing address:
  • Phone: 857-498-4996
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number2901602938
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number35770
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: