| NPI | 1023490588 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CO 00202832) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 2901021610) |
| Enumeration Date | 2015-06-22 |
| Last Update Date | 2016-07-08 |