Healthcare Provider Details

I. General information

NPI: 1538358759
Provider Name (Legal Business Name): DR. MAYA SHANTIKUMAR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2007
Last Update Date: 10/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8326 N SAGINAW RD
MOUNT MORRIS MI
48458-1648
US

IV. Provider business mailing address

1301 ORLEANS ST APARTMENT 1609
DETROIT MI
48207-2907
US

V. Phone/Fax

Practice location:
  • Phone: 810-687-5040
  • Fax:
Mailing address:
  • Phone: 810-687-5040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901019717
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: