Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 4301078052 | MI |
N | 1223S0112X | Oral and Maxillofacial Surgeon | 4301078052 | MI |
Y | 208200000X | Surgeon | 4301078052 | MI |
Y | 208600000X | Surgeon | 4301078052 | MI |
NPI | 1073611794 |
---|---|
Provider Name | Brent B Ward |
First Address | Ann Arbor, MI 48108-1633 |
Second Address | Ann Arbor, MI 48109-5000 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/09/2006 |
Last Update Date | 19/11/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
4525210 | (05) | MI |
U95937 | (02) | MI |