| NPI | 1154311181 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MN D11114) |
| Additional Taxonomies | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: MN D11114) |
| Enumeration Date | 2005-10-21 |
| Last Update Date | 2014-08-07 |