| NPI | 1033362793 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MI 2901019855) |
| Additional Taxonomies | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: MI 2901019855) |
| Enumeration Date | 2008-10-28 |
| Last Update Date | 2021-08-18 |