Healthcare Provider Details

I. General information

NPI: 1104329473
Provider Name (Legal Business Name): ANDREW THOMAS DAABOUS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2018
Last Update Date: 04/11/2022
Certification Date: 04/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20392 EUREKA RD
TAYLOR MI
48180-5310
US

IV. Provider business mailing address

2700 MARTIN LUTHER KING JR BLVD
DETROIT MI
48208-2576
US

V. Phone/Fax

Practice location:
  • Phone: 734-284-4300
  • Fax:
Mailing address:
  • Phone: 313-494-6606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2901600696
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: