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General NPI Number Information
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NPI Number | 1912400128
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Entity Type | Organization
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Legal Business Name | AWESOME DENTAL
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Dates
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Enumeration Date | 03/14/2018
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Last Update Date | 03/14/2018
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Provider Practice Location Address
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Address Line | 36000 FIVE MILE RD
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City | LIVONIA
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State | MI
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Zip | 48154-1918
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Country | US
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Telephone | 734-464-3430
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Fax | 734-464-6206
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Provider Business Mailing Address
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Address Line | 36000 FIVE MILE RD
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City | LIVONIA
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State | MI
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Zip | 48154-1918
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | DDS
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Name | DR. MARK JOHN HALBOTH
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Credential |
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Telephone | 734-464-3430
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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 | 13751
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License Number State | MI
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