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General NPI Number Information
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NPI Number | 1730569997
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Entity Type | Organization
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Legal Business Name | CLEAN SMILE DENTAL INC
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Dates
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Enumeration Date | 06/03/2015
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Last Update Date | 06/03/2015
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Provider Practice Location Address
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Address Line | 2213 N ROSEVERE AVE
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City | DEARBORN
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State | MI
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Zip | 48128-1244
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Country | US
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Telephone | 313-704-2886
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 144
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City | DEARBORN HEIGHTS
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State | MI
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Zip | 48127-0144
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Country | US
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Telephone | 313-704-2886
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | NAWAL SALAME
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Credential | RDH
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Telephone | 313-704-2886
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 124Q00000X
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Taxonomy Name | Dental Hygienist
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License Number | 2902010443
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License Number State | MI
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