Healthcare Provider Details

I. General information

NPI: 1245907070
Provider Name (Legal Business Name): ANASS KOLEILAT DDS,MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2021
Last Update Date: 10/21/2021
Certification Date: 10/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32316 5 MILE RD
LIVONIA MI
48154-6109
US

IV. Provider business mailing address

120 MEYER RD APT 622
AMHERST NY
14226-1015
US

V. Phone/Fax

Practice location:
  • Phone: 734-523-8300
  • Fax:
Mailing address:
  • Phone: 716-544-6161
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number2901601126
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number2901601126
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: