Healthcare Provider Details

I. General information

NPI: 1710816459
Provider Name (Legal Business Name): LIFETIME DENTAL OF MACOMB PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2026
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28050 HARPER AVE
SAINT CLAIR SHORES MI
48081-1562
US

IV. Provider business mailing address

3024 MANGROVE DR
STERLING HEIGHTS MI
48314-4407
US

V. Phone/Fax

Practice location:
  • Phone: 586-774-6655
  • Fax:
Mailing address:
  • Phone: 586-940-0123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MARK OUSACHI
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 586-940-0123