| NPI | 1164045738 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MN D14360) |
| Additional Taxonomies | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: MN D14360) |
| Enumeration Date | 2020-05-18 |
| Last Update Date | 2020-05-18 |