Healthcare Provider Details

I. General information

NPI: 1619582301
Provider Name (Legal Business Name): ZOMA DENTAL PRACTICE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2020
Last Update Date: 03/28/2023
Certification Date: 03/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6330 ORCHARD LAKE RD STE 130
WEST BLOOMFIELD MI
48322-2398
US

IV. Provider business mailing address

6330 ORCHARD LAKE RD STE 130
WEST BLOOMFIELD MI
48322-2398
US

V. Phone/Fax

Practice location:
  • Phone: 248-932-0550
  • Fax:
Mailing address:
  • Phone: 248-932-0550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: DR. JACQUELINE ZOMA
Title or Position: DENTIST
Credential: DDS
Phone: 248-807-1420