| NPI | 1093847576 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MI 10614) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 2901010614) |
| Enumeration Date | 2007-03-11 |
| Last Update Date | 2022-05-18 |