Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 4301111526 | MI |
N | 1223S0112X | Oral and Maxillofacial Surgeon | 4301111526 | MI |
Y | 204E00000X | Oral & Maxillofacial Surgeon | 4301111526 | MI |
N | 208200000X | Surgeon | 4301111526 | MI |
N | 208600000X | Surgeon | 4301111526 | MI |
NPI | 1104143833 |
---|---|
Provider Name | Justine Sherylyn Moe |
First Address | Ann Arbor, MI 48108-1633 |
Second Address | Ann Arbor, MI 48109-5000 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/04/2010 |
Last Update Date | 19/11/2020 |