| NPI | 1528567401 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | RANDALL SHAW Manager 248-931-1151 |
| Organization Subpart ? | Yes |
| Primary Taxonomy | 261QD0000X Clinic/Center, Dental |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 2901013819) |
| 1223G0001X Dentist, General Practice (Licence: MI 2901010706) | |
| Enumeration Date | 2018-02-06 |
| Last Update Date | 2020-11-24 |