=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215219233
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WARREN LASER DENTISTRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2011
-----------------------------------------------------
Last Update Date | 09/15/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4224 E 10 MILE RD
-----------------------------------------------------
City | WARREN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48091-1577
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-756-6351
-----------------------------------------------------
Fax | 586-756-6253
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4224 E 10 MILE RD
-----------------------------------------------------
City | WARREN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48091-1577
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-756-6351
-----------------------------------------------------
Fax | 586-756-6253
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | HAIFA MANSOUR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 586-756-6351
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------