Provider Demographics
NPI:1902473374
Name:BLOOMFIELD HILLS DENTAL GROUP PLLC
Entity Type:Organization
Organization Name:BLOOMFIELD HILLS DENTAL GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OMAR
Authorized Official - Middle Name:
Authorized Official - Last Name:ELBANHAWY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-335-4427
Mailing Address - Street 1:43902 WOODWARD AVE STE 220
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48302-5022
Mailing Address - Country:US
Mailing Address - Phone:248-335-4427
Mailing Address - Fax:248-332-2014
Practice Address - Street 1:43902 WOODWARD AVE STE 220
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48302-5022
Practice Address - Country:US
Practice Address - Phone:248-335-4427
Practice Address - Fax:248-332-2014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-05
Last Update Date:2021-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty