Healthcare Provider Details

I. General information

NPI: 1912923855
Provider Name (Legal Business Name): GHABI A. KASPO DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 08/08/2023
Certification Date: 08/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 E 2ND ST
ROYAL OAK MI
48067-2694
US

IV. Provider business mailing address

1 FORD PL STE 3A
DETROIT MI
48202-3450
US

V. Phone/Fax

Practice location:
  • Phone: 800-653-6568
  • Fax: 313-876-1305
Mailing address:
  • Phone: 313-876-4806
  • Fax: 248-546-2157

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number0015677
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2901015677
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code1223X2210X
TaxonomyOrofacial Pain Dentistry
License Number0015677
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code1223X2210X
TaxonomyOrofacial Pain Dentistry
License Number2901015677
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: