| NPI | 1063687077 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: AZ 7739) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 2901016560) |
| Enumeration Date | 2008-04-30 |
| Last Update Date | 2010-03-15 |