=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215476387
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELITE SMILE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/21/2017
-----------------------------------------------------
Last Update Date | 02/21/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 714 PATRICIA PLACE DR
-----------------------------------------------------
City | WESTLAND
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48185-3895
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-502-6663
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 714 PATRICIA PLACE DR
-----------------------------------------------------
City | WESTLAND
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48185-3895
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-502-6663
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DESNTIST
-----------------------------------------------------
Name | DR. NIDA ALSHAIKH
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 734-502-6663
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 2901018547
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------