Healthcare Provider Details

I. General information

NPI: 1427130079
Provider Name (Legal Business Name): MARK ALEX OBREGON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35900 FIVE MILE RD
LIVONIA MI
48154
US

IV. Provider business mailing address

35900 FIVE MILE RD
LIVONIA MI
48154
US

V. Phone/Fax

Practice location:
  • Phone: 734-464-7770
  • Fax: 734-464-7838
Mailing address:
  • Phone: 734-464-7770
  • Fax: 734-464-7838

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901016400
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: