Healthcare Provider Details

I. General information

NPI: 1518887355
Provider Name (Legal Business Name): KALLI DENTAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2026
Last Update Date: 07/21/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

363 W 12 MILE RD
MADISON HEIGHTS MI
48071-2403
US

IV. Provider business mailing address

363 W 12 MILE RD
MADISON HEIGHTS MI
48071-2403
US

V. Phone/Fax

Practice location:
  • Phone: 248-504-1881
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: GAVIN KALLABAT
Title or Position: DENTIST
Credential: DMD
Phone: 248-504-1881