=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720102676
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WALLEED MAMMO DDS,P.C AND ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/18/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 35450 DEQUINDRE RD SUIT 101
-----------------------------------------------------
City | STERLING HTS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48310-4810
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-264-6550
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 35450 DEQUINDRE RD SUIT 101
-----------------------------------------------------
City | STERLING HTS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48310-4810
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-264-6550
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER DENTIST
-----------------------------------------------------
Name | DR. WALEED MAMMO
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 248-217-9087
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 2901015678
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------