Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0700X | Prosthodontist | 2901601005 | MI |
NPI | 1003296781 |
---|---|
Provider Name | Dr. Robert Graham Greenland |
First Address | Grand Rapids, MI 49546-3682 |
Second Address | Grand Rapids, MI 49546-3682 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 08/06/2015 |
Last Update Date | 04/01/2022 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
2901601005 | PROSTHODONTIC LICENSE (01) | MI |