Healthcare Provider Details

I. General information

NPI: 1780502666
Provider Name (Legal Business Name): MICHELLE ELIZABETH MUKHTAR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2026
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20307 W 12 MILE RD STE 101
SOUTHFIELD MI
48076-5407
US

IV. Provider business mailing address

140 CANTERBURY RD
BLOOMFIELD HILLS MI
48304-2916
US

V. Phone/Fax

Practice location:
  • Phone: 248-775-2358
  • Fax:
Mailing address:
  • Phone: 248-762-9365
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number5315269040
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: