Provider Demographics
NPI:1588395495
Name:DAWISHA, DAVREN (DMD)
Entity type:Individual
Prefix:DR
First Name:DAVREN
Middle Name:
Last Name:DAWISHA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6929 MAPLE CREEK BLVD
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-4559
Mailing Address - Country:US
Mailing Address - Phone:248-904-5124
Mailing Address - Fax:
Practice Address - Street 1:23528 JOHN R RD
Practice Address - Street 2:
Practice Address - City:HAZEL PARK
Practice Address - State:MI
Practice Address - Zip Code:48030-1409
Practice Address - Country:US
Practice Address - Phone:248-397-1165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-21
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901601320122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist