MEDICARE: OBADA DOUGLAS

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	390200000X	Student in an Organized Health Care Education/Training Program
2	122300000X	Dentist	2901601713	MI

General Provider Information

NPI Number	:	1811691082
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OBADA DOUGLAS

Provider Business Mailing Address
First Line	:	27056 NORTHMORE ST
Second Line	:
City	:	DEARBORN HEIGHTS
State	:	MI
Zip	:	48127-3644
Country	:	US
Telephone Number	:	313-471-0820
Fax Number	:

Provider Business Practice Location Address
First Line	:	2850 US HIGHWAY 41 W
Second Line	:
City	:	MARQUETTE
State	:	MI
Zip	:	49855-2253
Country	:	US
Telephone Number	:	906-629-1369
Fax Number	:

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

Provider Enumeration Date	:	03/29/2023
Last Update Date	:	06/01/2023

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Directions to “ OBADA DOUGLAS ” Practice Location

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