MEDICARE: JOSEPH AZZOUZ DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	2901600231	MI
2	122300000X	Dentist	2901600231	MI

General Provider Information

NPI Number	:	1104471887
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOSEPH AZZOUZ DDS

Provider Business Mailing Address
First Line	:	16968 BROOKLANE BLVD
Second Line	:
City	:	NORTHVILLE
State	:	MI
Zip	:	48168-8422
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	24366 GRAND RIVER AVE
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48219-3098
Country	:	US
Telephone Number	:	248-924-7773
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/08/2019
Last Update Date	:	08/08/2019

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