| NPI | 1144518838 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 27165) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MI 2901021063) |
| Enumeration Date | 2011-07-14 |
| Last Update Date | 2024-03-06 |