Healthcare Provider Details

I. General information

NPI: 1558455592
Provider Name (Legal Business Name): SANILAC FAMILY DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

749 N SANDUSKY RD
SANDUSKY MI
48471-9143
US

IV. Provider business mailing address

3210 BRIARFIELD BLVD
MAUMEE OH
43537-9501
US

V. Phone/Fax

Practice location:
  • Phone: 810-648-3224
  • Fax: 810-648-4411
Mailing address:
  • Phone: 419-866-2400
  • Fax: 419-866-5320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number17451
License Number StateMI

VIII. Authorized Official

Name: DR. HISHAM KALOTI
Title or Position: DENIST/OWNER
Credential: DDS
Phone: 419-866-2400