=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568907152
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REKHA PALLI DENTAL PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/05/2017
-----------------------------------------------------
Last Update Date | 01/05/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 48224 HEATHER CT
-----------------------------------------------------
City | NORTHVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48168-8530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-756-7258
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4081 S CANTON CENTER RD
-----------------------------------------------------
City | CANTON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48188-2488
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | GENERAL DENTIST
-----------------------------------------------------
Name | DR. REKHA MADHURI PALLI
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 248-756-7258
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 2901020008
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------