1639738743 NPI number — ORTHODONTICS CENTER OF NOVI, PC

Table of content: (NPI 1639738743)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639738743 NPI number — ORTHODONTICS CENTER OF NOVI, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ORTHODONTICS CENTER OF NOVI, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639738743
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/12/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2211 MONROE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DEARBORN
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48124-3007
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-565-0880
Provider Business Mailing Address Fax Number:
313-565-2305

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
27250 WIXOM RD STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NOVI
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48374-1116
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-565-0880
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/12/2019

Additional Information

Authorized Official

Authorized Official Last Name:
SIDDIQUI
Authorized Official First Name:
MAMNOON
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
313-565-0880

Provider Taxonomy Codes

  • Taxonomy code: 1223X0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1336225713 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com