| NPI | 1093446890 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MN D15404) |
| Additional Taxonomies | 122300000X Dentist (Licence: FL 27727) |
| 122300000X Dentist (Licence: WI 600101415) | |
| 122300000X Dentist (Licence: MO 2024003610) | |
| Enumeration Date | 2022-06-22 |
| Last Update Date | 2026-01-02 |