MEDICARE: ANSARI DENTAL OF TROY PLLC

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	261QD0000X	Dental Clinic/Center	2901020901	MI

General Provider Information

NPI Number	:	1306334503
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANSARI DENTAL OF TROY PLLC

Provider Business Mailing Address
First Line	:	3962 ROCHESTER RD
Second Line	:
City	:	TROY
State	:	MI
Zip	:	48083-5248
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3962 ROCHESTER RD
Second Line	:
City	:	TROY
State	:	MI
Zip	:	48083-5248
Country	:	US
Telephone Number	:	248-891-6735
Fax Number	:

Authorized Official
Title or Position	:	BILLER
Name	:	TONYA WALKER
Credential	:
Telephone Number	:	248-891-6735

Provider Enumeration Date	:	04/24/2018
Last Update Date	:	04/24/2018

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