| NPI | 1164647780 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MI 2901019423) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DE00009575) |
| 122300000X Dentist (Licence: CA 53548) | |
| Enumeration Date | 2007-04-17 |
| Last Update Date | 2007-07-08 |