MEDICARE: AAA ORCHARD DENTAL PC

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		MI

General Provider Information

NPI Number	:	1437227261
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AAA ORCHARD DENTAL PC

Provider Business Mailing Address
First Line	:	6765 ORCHARD LAKE RD
Second Line	:
City	:	WEST BLOOMFIELD
State	:	MI
Zip	:	48322
Country	:	US
Telephone Number	:	248-851-6166
Fax Number	:	248-851-0012

Provider Business Practice Location Address
First Line	:	6765 ORCHARD LAKE RD
Second Line	:
City	:	WEST BLOOMFIELD
State	:	MI
Zip	:	48322
Country	:	US
Telephone Number	:	248-851-6166
Fax Number	:	248-851-0012

Authorized Official
Title or Position	:	PRESIDENT
Name	:	NIZAR NAUM MANSOUR
Credential	:	DDS MS
Telephone Number	:	248-851-6166

Provider Enumeration Date	:	12/01/2006
Last Update Date	:	08/22/2020

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