| NPI | 1013995505 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: TX 22585) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: MI 2901018456) |
| 1223G0001X Dentist General Practice (Licence: NC 7722) | |
| Enumeration Date | 2006-01-04 |
| Last Update Date | 2023-03-07 |