| NPI | 1134532906 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MN D13563) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NC AC5385578-R103) |
| Enumeration Date | 2014-06-09 |
| Last Update Date | 2015-07-07 |