| NPI | 1114975638 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MI 14052) |
| Additional Taxonomies | 101Y00000X Counselor (Licence: MI 6401011696) |
| Enumeration Date | 2006-05-05 |
| Last Update Date | 2016-02-12 |