| NPI | 1366954836 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | RANDALL SHAW Manager 248-931-1151 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QD0000X Clinic/Center, Dental |
| Additional Taxonomies | 1223G0001X Dentist, General Practice |
| Enumeration Date | 2017-10-24 |
| Last Update Date | 2018-09-05 |