| NPI | 1144605403 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0700X Dentist Prosthodontics (Licence: UT 10220776-8903) |
| Additional Taxonomies | 1223P0700X Dentist Prosthodontics (Licence: MI 2901021479) |
| 1223G0001X Dentist General Practice (Licence: MI 2901021479) | |
| Enumeration Date | 2015-07-28 |
| Last Update Date | 2023-09-19 |