Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223X0400X | Orthodontists | 19043 | MI |
NPI | 1063604890 |
---|---|
Provider Name | Edward Louis Grubaugh |
First Address | Lansing, MI 48917-4085 |
Second Address | Lansing, MI 48917-4085 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/08/2007 |
Last Update Date | 15/08/2007 |