1558434480 NPI number — SUHEIL M BOUTROS DDS MS

Table of content: SUHEIL M BOUTROS DDS MS (NPI 1558434480)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558434480 NPI number — SUHEIL M BOUTROS DDS MS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOUTROS
Provider First Name:
SUHEIL
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DDS MS
Provider Gender Code:
M

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:
1558434480
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/01/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5900 GEDDES RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YPSILANTI
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48198-9556
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-485-3994
Provider Business Mailing Address Fax Number:
810-732-4704

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 E LONG LAKE
Provider Second Line Business Practice Location Address:
SUITE 290
Provider Business Practice Location Address City Name:
BLOOMFIELD HILLS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48304
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-647-0516
Provider Business Practice Location Address Fax Number:
248-433-1664
Provider Enumeration Date:
11/16/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223P0300X , with the licence number:  16909 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223P0300X , with the licence number: 2901016909 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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