MEDICARE: HASSAN MAZLOUM

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	2901601787	MI

General Provider Information

NPI Number	:	1417669920
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HASSAN MAZLOUM

Provider Business Mailing Address
First Line	:	26439 SIMS ST
Second Line	:
City	:	DEARBORN HEIGHTS
State	:	MI
Zip	:	48127-4129
Country	:	US
Telephone Number	:	313-888-6188
Fax Number	:

Provider Business Practice Location Address
First Line	:	139 W LAKE LANSING RD, UNIT 200
Second Line	:
City	:	EAST LANSING
State	:	MI
Zip	:	48823-4129
Country	:	US
Telephone Number	:	313-888-6188
Fax Number	:

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

Provider Enumeration Date	:	12/15/2022
Last Update Date	:	06/26/2023

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Directions to “ HASSAN MAZLOUM ” Practice Location

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