Healthcare Provider Details

I. General information

NPI: 1902389984
Provider Name (Legal Business Name): MICHIGAN FAMILY DENTISTRY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2018
Last Update Date: 03/04/2021
Certification Date: 03/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26699 W 12 MILE RD STE 200
SOUTHFIELD MI
48034-7815
US

IV. Provider business mailing address

26699 W 12 MILE RD STE 200
SOUTHFIELD MI
48034-7815
US

V. Phone/Fax

Practice location:
  • Phone: 248-626-6526
  • Fax: 248-626-6529
Mailing address:
  • Phone: 248-626-6526
  • Fax: 248-626-6529

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number
License Number State

VIII. Authorized Official

Name: DR. RAMI JANDALI
Title or Position: OWNER
Credential: DMD, MS
Phone: 248-626-6526