| NPI | 1093971749 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: AZ 7708) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 2901019386) |
| 1223P0221X Dentist, Pediatric Dentistry (Licence: MI 2901019386) | |
| Enumeration Date | 2008-08-01 |
| Last Update Date | 2010-11-09 |