MEDICARE: KHOURY DENTAL CENTER, 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	1223G0001X	General Practice Dentistry	2901018892	MI

General Provider Information

NPI Number	:	1780841767
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KHOURY DENTAL CENTER, PLLC

Provider Business Mailing Address
First Line	:	1120 S LAPEER RD
Second Line	:	STE 100
City	:	OXFORD
State	:	MI
Zip	:	48371-6102
Country	:	US
Telephone Number	:	248-969-7645
Fax Number	:	248-969-7646

Provider Business Practice Location Address
First Line	:	1120 S LAPEER RD
Second Line	:	STE 100
City	:	OXFORD
State	:	MI
Zip	:	48371-6102
Country	:	US
Telephone Number	:	248-969-7645
Fax Number	:	248-969-7646

Authorized Official
Title or Position	:	MEMBER
Name	:	DR. JOHN MICHAEL KHOURY JR.
Credential	:	D.D.S.
Telephone Number	:	248-969-7645

Provider Enumeration Date	:	05/19/2008
Last Update Date	:	05/19/2008

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