Organization
LIVONIA LASER DENTISTRY
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. FADY MANSOUR (ADMIN)
(734) 425-6920
Entity
Organization
Contact information
Practice address
31632 SCHOOLCRAFT RD, LIVONIA, MI 48150-1819
(734) 425-6920
(734) 425-1541
Mailing address
31632 SCHOOLCRAFT RD, LIVONIA, MI 48150-1819
(734) 425-6920
(734) 425-1541
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
2901017025
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
13167481
—
MI
01
—
2901017025
MICHIGAN PROFESSIONAL LICENSE - DENTISY
MI
Enumeration date
08/09/2018
Last updated
08/09/2018
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