Provider Demographics
NPI:1891276283
Name:HUSSEIN, KHADIJE
Entity type:Individual
Prefix:DR
First Name:KHADIJE
Middle Name:
Last Name:HUSSEIN
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 1:29475 PLYMOUTH RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-2112
Mailing Address - Country:US
Mailing Address - Phone:734-237-5755
Mailing Address - Fax:734-237-5756
Practice Address - Street 1:29475 PLYMOUTH RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48150-2112
Practice Address - Country:US
Practice Address - Phone:734-237-5755
Practice Address - Fax:734-237-5756
Is Sole Proprietor?:No
Enumeration Date:2018-08-24
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901022644122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2901022644Medicaid