| NPI | 1124082243 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MN D13757) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: IA 08246) |
| 1223G0001X Dentist, General Practice (Licence: SC 8189) | |
| Enumeration Date | 2006-04-14 |
| Last Update Date | 2016-09-09 |