Provider Demographics
NPI:1285354787
Name:IMTIAZ, MAHVEEN
Entity type:Individual
Prefix:
First Name:MAHVEEN
Middle Name:
Last Name:IMTIAZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3646 MOUNT ELLIOTT ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48207-2311
Mailing Address - Country:US
Mailing Address - Phone:313-626-2400
Mailing Address - Fax:
Practice Address - Street 1:3646 MOUNT ELLIOTT ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-2311
Practice Address - Country:US
Practice Address - Phone:313-626-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-02
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901601481122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist