MEDICARE: DENTAL HOUSE - WATERFORD, 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
2	122300000X	Dentist

General Provider Information

NPI Number	:	1700418555
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTAL HOUSE - WATERFORD, PLLC

Provider Business Mailing Address
First Line	:	4860 WASHTENAW AVE STE D
Second Line	:
City	:	ANN ARBOR
State	:	MI
Zip	:	48108-3401
Country	:	US
Telephone Number	:	804-539-6622
Fax Number	:

Provider Business Practice Location Address
First Line	:	5979 HIGHLAND ROAD
Second Line	:
City	:	WATERFORD TWP
State	:	MI
Zip	:	48327
Country	:	US
Telephone Number	:	734-999-9909
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	RAMY ATTALLA
Credential	:	DMD
Telephone Number	:	804-539-6622

Provider Enumeration Date	:	02/10/2020
Last Update Date	:	02/10/2020

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