| NPI | 1154733095 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WI 1001487-15) |
| Additional Taxonomies | 122300000X Dentist (Licence: MN D13373) |
| Enumeration Date | 2014-05-27 |
| Last Update Date | 2019-04-17 |