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General NPI Number Information
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NPI Number | 1912389842
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Entity Type | Organization
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Legal Business Name | PROFESSIONAL DENTAL ALLIANCE OF MICHIGAN, LLC
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Dates
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Enumeration Date | 06/27/2015
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Last Update Date | 06/27/2015
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Provider Practice Location Address
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Address Line | 23528 JOHN R RD
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City | HAZEL PARK
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State | MI
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Zip | 48030-1409
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Country | US
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Telephone | 248-397-1165
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Fax |
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Provider Business Mailing Address
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Address Line | 23528 JOHN R RD
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City | HAZEL PARK
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State | MI
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Zip | 48030-1409
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Country | US
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Telephone | 248-397-1165
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | DR. SHAKIB HALABU
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Credential |
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Telephone | 248-397-1165
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 2901011201
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License Number State | MI
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