| NPI | 1144656356 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: VA 0401414352) |
| Additional Taxonomies | 1223P0221X Dentist, Pediatric Dentistry (Licence: MI 2901020826) |
| Enumeration Date | 2013-09-19 |
| Last Update Date | 2015-08-20 |