Provider Demographics
NPI:1023261617
Name:ST.GEORGE FAMILY DENTISTRY P.C
Entity type:Organization
Organization Name:ST.GEORGE FAMILY DENTISTRY P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ALAA
Authorized Official - Middle Name:K
Authorized Official - Last Name:HERMIZ
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:248-548-2210
Mailing Address - Street 1:10470 W 9 MILE RD
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48237-2914
Mailing Address - Country:US
Mailing Address - Phone:248-548-2210
Mailing Address - Fax:248-548-1769
Practice Address - Street 1:10470 W 9 MILE RD
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:MI
Practice Address - Zip Code:48237-2914
Practice Address - Country:US
Practice Address - Phone:248-548-2210
Practice Address - Fax:248-548-1769
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-28
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL29010183051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4547942Medicaid