| NPI | 1053901330 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: MN S166) |
| Additional Taxonomies | 1223P0300X Dentist, Periodontics (Licence: VA 0401417229) |
| Enumeration Date | 2021-01-21 |
| Last Update Date | 2021-06-16 |