Healthcare Provider Details

I. General information

NPI: 1154111920
Provider Name (Legal Business Name): JADE MOURAD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2025
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8136 21 MILE RD
SHELBY TOWNSHIP MI
48317-4312
US

IV. Provider business mailing address

800 MICHAUX LN
GROSSE POINTE SHORES MI
48236-1401
US

V. Phone/Fax

Practice location:
  • Phone: 586-726-2273
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2951000996
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: