=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245036953
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEW TROY GROUP DENTAL PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2025
-----------------------------------------------------
Last Update Date | 02/22/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6053 ROCHESTER RD
-----------------------------------------------------
City | TROY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48085-1303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-558-2785
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6053 ROCHESTER RD
-----------------------------------------------------
City | TROY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48085-1303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-558-2785
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST/PARTNER
-----------------------------------------------------
Name | DR. BRANDON SAM KHADDOR
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 586-804-8118
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------