| NPI | 1033207139 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: MI 2901011291) |
| Additional Taxonomies | 332B00000X Durable Medical Equipment & Medical Supplies (Licence: MI 2901011291) |
| Enumeration Date | 2006-10-11 |
| Last Update Date | 2019-06-27 |