Provider Demographics
NPI:1053549782
Name:GHATTAS, SIMON MINA (DMD, MS)
Entity type:Individual
Prefix:DR
First Name:SIMON
Middle Name:MINA
Last Name:GHATTAS
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1460 WALTON BLVD
Mailing Address - Street 2:#208
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48309-1768
Mailing Address - Country:US
Mailing Address - Phone:561-317-4805
Mailing Address - Fax:248-656-3147
Practice Address - Street 1:1460 WALTON BLVD
Practice Address - Street 2:#208
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48309-1768
Practice Address - Country:US
Practice Address - Phone:561-317-4805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-01
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL755122300000X
MI29010203211223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No122300000XDental ProvidersDentist