| NPI | 1093121972 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MI 2901021460) |
| Additional Taxonomies | 122300000X Dentist (Licence: NC 150984) |
| Enumeration Date | 2014-07-11 |
| Last Update Date | 2018-12-04 |