1689193278 NPI number — ENNIS MALIK BEDAIR BDS

Table of content: ENNIS MALIK BEDAIR BDS (NPI 1689193278)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689193278 NPI number — ENNIS MALIK BEDAIR BDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BEDAIR
Provider First Name:
ENNIS
Provider Middle Name:
MALIK
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
BDS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MOHAMMED
Provider Other First Name:
ANAS
Provider Other Middle Name:
MALIK
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1689193278
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/25/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1500 E. MEDICAL CENTER DR., TOWSLEY CENTER G1218
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANN ARBOR
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48109-5222
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1500 E. MEDICAL CENTER DR., MED INN C213A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANN ARBOR
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48109
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-936-5950
Provider Business Practice Location Address Fax Number:
734-232-5015
Provider Enumeration Date:
09/14/2017

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: 122300000X , with the licence number:  2952000370 , 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)