Healthcare Provider Details

I. General information

NPI: 1073439725
Provider Name (Legal Business Name): LELYAN ODEH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2026
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30555 SOUTHFIELD RD STE 310
SOUTHFIELD MI
48076-7752
US

IV. Provider business mailing address

26976 HAVELOCK DR
DEARBORN HEIGHTS MI
48127-3639
US

V. Phone/Fax

Practice location:
  • Phone: 248-965-8707
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901603230
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: