| NPI | 1013060052 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: MI 2901018621) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 2901018621) |
| Enumeration Date | 2007-01-21 |
| Last Update Date | 2014-09-10 |