Healthcare Provider Details

I. General information

NPI: 1427598598
Provider Name (Legal Business Name): DR. AMRUTA MAHAJAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2017
Last Update Date: 03/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2425 E 12 MILE RD
WARREN MI
48092-5667
US

IV. Provider business mailing address

1327 S MAIN ST
ROYAL OAK MI
48067-3267
US

V. Phone/Fax

Practice location:
  • Phone: 586-573-7334
  • Fax:
Mailing address:
  • Phone: 615-957-7554
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number2901022145
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: