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General NPI Number Information
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NPI Number | 1992480610
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Entity Type | Individual
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Provider Name | THOMAS MARK KHEMMORO DDS
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Gender | Male
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Dates
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Enumeration Date | 06/20/2023
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Last Update Date | 06/20/2023
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Provider Practice Location Address
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Address Line | 44968 FORD RD STE R
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City | CANTON
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State | MI
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Zip | 48187-2900
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Country | US
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Telephone | 734-386-7000
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Fax |
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Provider Business Mailing Address
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Address Line | 3828 MYSTIC VALLEY DR
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City | BLOOMFIELD HILLS
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State | MI
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Zip | 48302-1437
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Country | US
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Telephone | 248-444-2617
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 2901601829
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License Number State | MI
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