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General NPI Number Information
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NPI Number | 1114586203
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Entity Type | Individual
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Provider Name | CAM HA DDS
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Gender | Male
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Dates
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Enumeration Date | 06/11/2019
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Last Update Date | 02/23/2026
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Provider Practice Location Address
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Address Line | 26298 GRATIOT AVE
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City | ROSEVILLE
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State | MI
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Zip | 48066-3375
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Country | US
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Telephone | 586-200-6720
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Fax |
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Provider Business Mailing Address
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Address Line | 17367 KERSHAW ST
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City | ROSEVILLE
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State | MI
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Zip | 48066-3345
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 11325173-9921
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License Number State | UT
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 40980
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License Number State | TX
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Taxonomy #3
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 2901602887
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License Number State | MI
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