=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285880872
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EASTLAND FAMILY DENTISTRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2008
-----------------------------------------------------
Last Update Date | 08/14/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16068 E 8 MILE RD
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48205-1416
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-372-8580
-----------------------------------------------------
Fax | 313-372-7739
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16068 E 8 MILE RD
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48205-1416
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-372-8580
-----------------------------------------------------
Fax | 313-372-7739
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. FADI G KEYORKGY
-----------------------------------------------------
Credential | D.D.S., M.S.D.
-----------------------------------------------------
Telephone | 313-372-8580
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 16598
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------