Healthcare Provider Details

I. General information

NPI: 1982107710
Provider Name (Legal Business Name): AMAZING DENTAL WYANDOTTE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2018
Last Update Date: 03/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1805 FORT ST
WYANDOTTE MI
48192-3545
US

IV. Provider business mailing address

4616 BENNINGTON DR
STERLING HEIGHTS MI
48310-3113
US

V. Phone/Fax

Practice location:
  • Phone: 248-910-4819
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. SHAMS HAMAMA
Title or Position: CREDENTIALING
Credential:
Phone: 248-910-4819