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General NPI Number Information
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NPI Number | 1346632122
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Entity Type | Organization
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Legal Business Name | MODERN DENTAL CENTER
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Dates
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Enumeration Date | 03/03/2015
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Last Update Date | 03/03/2015
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Provider Practice Location Address
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Address Line | 50810 ROMEO PLANK RD
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City | MACOMB
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State | MI
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Zip | 48044-1123
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Country | US
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Telephone | 734-644-7815
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Fax |
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Provider Business Mailing Address
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Address Line | 50810 ROMEO PLANK RD
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City | MACOMB
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State | MI
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Zip | 48044-1123
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Country | US
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Telephone | 734-644-7815
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MAHA ZETOUNA
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Credential | DDS
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Telephone | 734-644-7815
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 16908
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License Number State | MI
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