Healthcare Provider Details

I. General information

NPI: 1194993428
Provider Name (Legal Business Name): DENTAL REHAB PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2008
Last Update Date: 06/24/2020
Certification Date: 06/24/2020
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 TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number2901017395
License Number StateMI

VIII. Authorized Official

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