| NPI | 1073683389 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: AZ D7936) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: MI 2901012561) |
| Enumeration Date | 2006-11-08 |
| Last Update Date | 2012-02-20 |