| NPI | 1063485654 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MN D11553) |
| Additional Taxonomies | 1223D0001X Dentist, Dental Public Health (Licence: MA 21460) |
| 1223G0001X Dentist, General Practice (Licence: MA 21460) | |
| 1223G0001X Dentist, General Practice (Licence: NH 3293) | |
| Enumeration Date | 2006-02-13 |
| Last Update Date | 2025-09-11 |