| NPI | 1811152358 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | LEE DAVID FREDERICKSON Owner 616-534-5602 |
| Organization Subpart ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MI 09607) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 12554) |
| Enumeration Date | 2008-07-24 |
| Last Update Date | 2008-07-24 |