Healthcare Provider Details

I. General information

NPI: 1780230730
Provider Name (Legal Business Name): LEEN KHATIB
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2019
Last Update Date: 08/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10460 PELHAM RD
TAYLOR MI
48180-3828
US

IV. Provider business mailing address

4466 AUGUSTA CT
ANN ARBOR MI
48108-9789
US

V. Phone/Fax

Practice location:
  • Phone: 313-299-9700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number2901022956
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2901022956APP19
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: