Healthcare Provider Details

I. General information

NPI: 1508778168
Provider Name (Legal Business Name): PARK DENTAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2026
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1880 EMMONS BLVD
LINCOLN PARK MI
48146-3866
US

IV. Provider business mailing address

1880 EMMONS BLVD
LINCOLN PARK MI
48146-3866
US

V. Phone/Fax

Practice location:
  • Phone: 313-388-8444
  • Fax:
Mailing address:
  • Phone: 313-388-8444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MOHAMAD BAZZI
Title or Position: OWNER/DENTIST
Credential: DMD
Phone: 313-587-3947