Healthcare Provider Details

I. General information

NPI: 1730529082
Provider Name (Legal Business Name): MOBILE DENTAL OF MICHIGAN, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2013
Last Update Date: 07/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50749 CHESAPEAKE DR
NOVI MI
48374-2551
US

IV. Provider business mailing address

8420 W BRYN MAWR AVE SUITE 300
CHICAGO IL
60631-3479
US

V. Phone/Fax

Practice location:
  • Phone: 773-756-5760
  • Fax:
Mailing address:
  • Phone: 773-756-5760
  • Fax: 773-714-1229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. AJAY V RAMAN
Title or Position: PRESIDENT
Credential: D.O.
Phone: 773-756-5760