Healthcare Provider Details

I. General information

NPI: 1912698176
Provider Name (Legal Business Name): ZIAD KUTOB DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2023
Last Update Date: 09/27/2023
Certification Date: 09/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8950 US HIGHWAY 64 STE 108
LAKELAND TN
38002-4566
US

IV. Provider business mailing address

8950 US HIGHWAY 64
LAKELAND TN
38002-4566
US

V. Phone/Fax

Practice location:
  • Phone: 734-741-3588
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN123133
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: