| NPI | 1063078210 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WI 1002126-15) |
| Additional Taxonomies | 122300000X Dentist (Licence: MN D14174) |
| 1223G0001X Dentist, General Practice (Licence: WI 1002126-15) | |
| 1223G0001X Dentist, General Practice (Licence: MN D14174) | |
| Enumeration Date | 2019-05-14 |
| Last Update Date | 2022-02-04 |