Healthcare Provider Details

I. General information

NPI: 1083392658
Provider Name (Legal Business Name): ANGELINE HARVILLE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2023
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29201 TELEGRAPH RD STE 110
SOUTHFIELD MI
48034-7630
US

IV. Provider business mailing address

1011 N UNIVERSITY AVE
ANN ARBOR MI
48109-1078
US

V. Phone/Fax

Practice location:
  • Phone: 124-835-8291
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number2901601866
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: