Provider Demographics
NPI:1063894319
Name:MIDWESTDENTAL OF DEARBORN
Entity type:Organization
Organization Name:MIDWESTDENTAL OF DEARBORN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ZAID
Authorized Official - Middle Name:
Authorized Official - Last Name:ANBAKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-565-1102
Mailing Address - Street 1:20055 CARLYSLE ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-3803
Mailing Address - Country:US
Mailing Address - Phone:313-565-1102
Mailing Address - Fax:
Practice Address - Street 1:20055 CARLYSLE ST
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-3803
Practice Address - Country:US
Practice Address - Phone:313-565-1102
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-23
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901021145122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty