Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223D0001X | Dental Public Health | 1223D0001X | MI |
NPI | 1750782504 |
---|---|
Provider Name | Mr. George Daniel |
First Address | Detroit, MI 48226-4592 |
Second Address | Detroit, MI 48226-4592 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 11/09/2014 |
Last Update Date | 11/09/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
RMR04 | (05) | MI |