Healthcare Provider Details

I. General information

NPI: 1841676822
Provider Name (Legal Business Name): MARIAM ROMMEL MAIZI DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2015
Last Update Date: 09/10/2021
Certification Date: 09/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31201 CHICAGO RD S STE A301
WARREN MI
48093-5523
US

IV. Provider business mailing address

31201 CHICAGO RD S STE A301
WARREN MI
48093-5523
US

V. Phone/Fax

Practice location:
  • Phone: 586-434-4040
  • Fax:
Mailing address:
  • Phone: 586-434-4040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number29010211560
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number5315071562
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: