Provider Demographics
NPI:1184724577
Name:AWANIS, FATIN (DDS PC)
Entity type:Individual
Prefix:MRS
First Name:FATIN
Middle Name:
Last Name:AWANIS
Suffix:
Gender:F
Credentials:DDS PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26400 W 12 MILE ROAD
Mailing Address - Street 2:SUITE 160
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034
Mailing Address - Country:US
Mailing Address - Phone:248-356-8567
Mailing Address - Fax:248-356-3442
Practice Address - Street 1:26400 W 12 MILE ROAD
Practice Address - Street 2:SUITE 160
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034
Practice Address - Country:US
Practice Address - Phone:248-356-8567
Practice Address - Fax:248-356-3442
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901073381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4376818Medicaid
D1733800Medicare UPIN