Provider Demographics
NPI:1043066210
Name:ELEWA, HESHAM
Entity type:Individual
Prefix:
First Name:HESHAM
Middle Name:
Last Name:ELEWA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37420 EMERALD FOREST DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48331-1182
Mailing Address - Country:US
Mailing Address - Phone:248-408-9658
Mailing Address - Fax:
Practice Address - Street 1:1615 CARLTON BLVD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49203-1444
Practice Address - Country:US
Practice Address - Phone:517-787-6776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-27
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901602319122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist