# LIVONIA LASER DENTISTRY

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1811476955
- **Authorized official:** MR. FADY MANSOUR (ADMIN)
- **Authorized official phone:** (734) 425-6920

## Contact information

- **Practice address:** 31632 SCHOOLCRAFT RD, LIVONIA, MI 48150-1819
- **Practice address phone:** (734) 425-6920
- **Practice address fax:** (734) 425-1541
- **Mailing address:** 31632 SCHOOLCRAFT RD, LIVONIA, MI 48150-1819
- **Mailing address phone:** (734) 425-6920
- **Mailing address fax:** (734) 425-1541

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223G0001X | General Practice Dentistry | 2901017025 | MI | Yes |

## Other

- **Enumeration date:** 08/09/2018
- **Last updated:** 08/09/2018

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 13167481 | — | MI |
| 01 | — | 2901017025 | MICHIGAN PROFESSIONAL LICENSE - DENTISY | MI |