| NPI | 1083895510 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: WI 1001156) |
| Additional Taxonomies | 122300000X Dentist (Licence: IA 09067) |
| 122300000X Dentist (Licence: WI 1001156) | |
| 1223P0221X Dentist, Pediatric Dentistry (Licence: MN S25) | |
| Enumeration Date | 2007-11-27 |
| Last Update Date | 2018-12-19 |