Healthcare Provider Details

I. General information

NPI: 1801535604
Provider Name (Legal Business Name): YOUSUF SIRAJELDIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2022
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7125 ORCHARD LAKE RD STE 310
WEST BLOOMFIELD MI
48322-3620
US

IV. Provider business mailing address

2263 HOLTON LN
WEST BLOOMFIELD MI
48323-3607
US

V. Phone/Fax

Practice location:
  • Phone: 248-855-1855
  • Fax: 248-855-3824
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019-034513
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number6001056-15
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number2901602493
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: