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Individual
CAM HA
Active
Individual
CAM HA
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DDS
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
11325173-9921
UT
1223G0001X
General Practice Dentistry
Primary
2901602887
MI
1223G0001X
General Practice Dentistry
40980
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
11325173-9921
SATE OF UTAH
UT
01
—
2901602887
STATEOFMICHIGAN
MI
Enumeration date
06/11/2019
Last updated
02/23/2026
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