Basic Information
Provider Information
NPI: 1629585179
EntityType: 2
ReplacementNPI:  
OrganizationName: DIAMOND FAMILY DENTAL
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 39042 DEQUINDRE RD
Address2:  
City: STERLING HEIGHTS
State: MI
PostalCode: 483101701
CountryCode: US
TelephoneNumber: 5869838333
FaxNumber: 5869838337
Practice Location
Address1: 39042 DEQUINDRE RD
Address2:  
City: STERLING HEIGHTS
State: MI
PostalCode: 483101701
CountryCode: US
TelephoneNumber: 5869838333
FaxNumber: 5869838337
Other Information
ProviderEnumerationDate: 01/05/2018
LastUpdateDate: 01/06/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: YOUSIF
AuthorizedOfficialFirstName: SALWAN
AuthorizedOfficialMiddleName: H
AuthorizedOfficialTitleorPosition: DMD
AuthorizedOfficialTelephone: 5869838333
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
122300000X  Y193400000X SINGLE SPECIALTY GROUPDental ProvidersDentist 

No ID Information.


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