Healthcare Provider Details

I. General information

NPI: 1073790838
Provider Name (Legal Business Name): FORT DENTAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2008
Last Update Date: 01/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3515 FORT ST
LINCOLN PARK MI
48146-4101
US

IV. Provider business mailing address

3515 FORT ST
LINCOLN PARK MI
48146-4101
US

V. Phone/Fax

Practice location:
  • Phone: 313-386-9404
  • Fax: 313-386-9405
Mailing address:
  • Phone: 313-386-9404
  • Fax: 313-386-9405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. FADI SAMMAN
Title or Position: OWNER/PARTNER
Credential: D.D.S.
Phone: 313-386-9404