| NPI | 1043384266 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MO 2005-007420) |
| Additional Taxonomies | 122300000X Dentist (Licence: ND 1892) |
| Enumeration Date | 2006-11-20 |
| Last Update Date | 2021-07-26 |