MEDICARE: AMAZING DENTAL WYANDOTTE 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

General Provider Information

NPI Number	:	1982107710
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AMAZING DENTAL WYANDOTTE PLLC

Provider Business Mailing Address
First Line	:	4616 BENNINGTON DR
Second Line	:
City	:	STERLING HEIGHTS
State	:	MI
Zip	:	48310-3113
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1805 FORT ST
Second Line	:
City	:	WYANDOTTE
State	:	MI
Zip	:	48192-3545
Country	:	US
Telephone Number	:	248-910-4819
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING
Name	:	MS. SHAMS HAMAMA
Credential	:
Telephone Number	:	248-910-4819

Provider Enumeration Date	:	03/18/2018
Last Update Date	:	03/18/2018

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