| NPI | 1104072867 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: VA 0401412245) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 2901019784) |
| Enumeration Date | 2008-08-13 |
| Last Update Date | 2008-08-13 |