Healthcare Provider Details

I. General information

NPI: 1013321165
Provider Name (Legal Business Name): RAYMOND JAMES HANNA D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2014
Last Update Date: 09/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3766 ELDER RD S
WEST BLOOMFIELD MI
48324-2534
US

IV. Provider business mailing address

3766 ELDER RD S
WEST BLOOMFIELD MI
48324-2534
US

V. Phone/Fax

Practice location:
  • Phone: 248-360-1180
  • Fax:
Mailing address:
  • Phone: 248-360-1180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2901009615
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: