| NPI | 1093171233 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: MI 2901021647) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 2901021647) |
| Enumeration Date | 2016-01-04 |
| Last Update Date | 2020-03-24 |