| NPI | 1053621516 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: TX 27429) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: MI 2901020312) |
| Enumeration Date | 2010-10-18 |
| Last Update Date | 2013-01-29 |