Healthcare Provider Details

I. General information

NPI: 1336592252
Provider Name (Legal Business Name): HAPPY TOOTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2016
Last Update Date: 07/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31207 RYAN RD
WARREN MI
48092-3761
US

IV. Provider business mailing address

31207 RYAN RD
WARREN MI
48092-3761
US

V. Phone/Fax

Practice location:
  • Phone: 586-553-9399
  • Fax:
Mailing address:
  • Phone: 586-553-9399
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State

VIII. Authorized Official

Name: DR. FATIN ASMER AWANIS
Title or Position: GENERAL DENTIST
Credential: D.D.S.P.C
Phone: 248-219-5863