Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0221X | Pediatric Dentist | 2901601028 | MI |
N | 1223P0221X | Pediatric Dentist | DF11463 | MA |
NPI | 1063824464 |
---|---|
Provider Name | Maria Al Ismail |
First Address | Canton, MI 48188-2863 |
Second Address | Detroit, MI 48208-2576 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/05/2014 |
Last Update Date | 02/09/2021 |