| NPI | 1144500349 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MI 2901020424) |
| Additional Taxonomies | 1223P0300X Dentist Periodontics (Licence: NE 7257) |
| Enumeration Date | 2011-08-19 |
| Last Update Date | 2021-09-21 |