| NPI | 1104307651 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: MI 2901600262) |
| Additional Taxonomies | 1223P0221X Dentist, Pediatric Dentistry (Licence: TX 38097) |
| Enumeration Date | 2018-08-23 |
| Last Update Date | 2022-03-22 |