=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801754536
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREAT LAKES DENTAL VENTURES PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2026
-----------------------------------------------------
Last Update Date | 01/12/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7437 JACKMAN RD
-----------------------------------------------------
City | TEMPERANCE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48182-9223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-847-1780
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7437 JACKMAN RD
-----------------------------------------------------
City | TEMPERANCE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48182-9223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-847-1780
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. IBRAHIM AHMAD AL-JERDI
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 734-931-2484
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------