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6044 24-Mile Road, Shelby Township, MI 48316
586.739.2155
Request Introductory Packet
* = Required Fields

Please send me info on the following
Practice Brochure Sleep Apnea Info TMJ Treatment Info
Cosmetic Dentistry Info Sedation Dentistry Info Tooth Replacement Options



Name:
*
Email Address:
*
Address:
*
City:
*
State:
*
Zip:
*
Daytime Phone:
*
Evening Phone:
Best Time to Reach Me:



I have a current dentist whom I see on a regular basis Yes   No
I am missing one or more natural teeth Yes   No
I wear a denture or partial Yes   No
I would like to improve the appearance of my smile Yes   No
I am fearful of dental visits and experience anxiety during them Yes   No
I have all my natural teeth & would like to keep them all my life Yes   No
I would like to discuss/arrange a group presentation on dentistry Yes   No
I am years old and am Male   Female
How did you find our website?


Please enter the code to continue.







6044 24-Mile Road, Shelby Township, MI 48316
586.739.2155

Contact Info

Dr. Ban R. Barbat 6044 24-Mile Road
Shelby Township, MI 48316
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