Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 755 | FL |
Y | 1223E0200X | Endodontist | 2901020321 | MI |
NPI | 1053549782 |
---|---|
Provider Name | Dr. Simon Mina Ghattas |
First Address | Rochester Hills, MI 48309-1768 |
Second Address | Rochester Hills, MI 48309-1768 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/07/2009 |
Last Update Date | 19/09/2012 |