Basic Information
| Provider Information | |||||||||
| NPI: | 1689193278 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BEDAIR | ||||||||
| FirstName: | ENNIS | ||||||||
| MiddleName: | MALIK | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | BDS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MOHAMMED | ||||||||
| OtherFirstName: | ANAS | ||||||||
| OtherMiddleName: | MALIK | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1500 E. MEDICAL CENTER DR., TOWSLEY CENTER G1218 | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481095222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1500 E. MEDICAL CENTER DR., MED INN C213A | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7349365950 | ||||||||
| FaxNumber: | 7342325015 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2017 | ||||||||
| LastUpdateDate: | 09/25/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 2952000370 | MI | Y | Dental Providers | Dentist |
No ID Information.