Healthcare Provider Details

I. General information

NPI: 1912814765
Provider Name (Legal Business Name): SOUTH LYON PEDIATRIC DENTISTRY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2026
Last Update Date: 08/26/2026
Certification Date: 08/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26808 PONTIAC TRAIL
SOUTH LYON MI
48178
US

IV. Provider business mailing address

51019 SILVERTON
CANTON MI
48187-7719
US

V. Phone/Fax

Practice location:
  • Phone: 857-272-2572
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. MARIA AL ISMAIL
Title or Position: MANAGING MEMBER
Credential: DDS
Phone: 734-926-8428