=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134576424
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIV DENTAL, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2016
-----------------------------------------------------
Last Update Date | 05/17/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 30003 SOUTHFIELD RD
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48076-1433
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-646-2273
-----------------------------------------------------
Fax | 248-646-2434
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 30003 SOUTHFIELD RD
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48076-1433
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-646-2273
-----------------------------------------------------
Fax | 248-646-2434
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MANPREET KAUR CHAHAL
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 248-321-9726
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------