Healthcare Provider Details

I. General information

NPI: 1235628744
Provider Name (Legal Business Name): HOUDA GHASSANI DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2018
Last Update Date: 06/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 W PIERSON RD # UNITSB-D
FLINT MI
48504
US

IV. Provider business mailing address

350 N CLARK ST
CHICAGO IL
60654-4712
US

V. Phone/Fax

Practice location:
  • Phone: 810-789-5880
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901022703
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: