1255179842 NPI number — DELUXE DENTAL ASSOCIATES 10- WATERFORD PLLC

Table of content: DR. MUHAMMAD SHAHZAD MUMTAZ ANSARI M.D. (NPI 1184937245)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255179842 NPI number — DELUXE DENTAL ASSOCIATES 10- WATERFORD PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DELUXE DENTAL ASSOCIATES 10- WATERFORD PLLC
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:
1255179842
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/17/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3760 S DORT HWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLINT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48507-2045
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-820-7766
Provider Business Mailing Address Fax Number:
810-243-0454

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1090 W HURON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WATERFORD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48328-3733
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-820-7766
Provider Business Practice Location Address Fax Number:
810-243-0454
Provider Enumeration Date:
07/17/2024

Additional Information

Authorized Official

Authorized Official Last Name:
MIKHA-KIZY
Authorized Official First Name:
AMBER
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
810-820-7766

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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