| NPI | 1033497805 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MI 2901021708) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA DL11350) |
| Enumeration Date | 2011-07-28 |
| Last Update Date | 2016-08-03 |