Individual
CAM HA
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DDS
Contact information
Practice address
26298 GRATIOT AVE, ROSEVILLE, MI 48066-3375
(586) 200-6720
Mailing address
17367 KERSHAW ST, ROSEVILLE, MI 48066-3345
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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