| NPI | 1174152581 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 37154) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: MI 2901600479) |
| Enumeration Date | 2020-04-07 |
| Last Update Date | 2023-03-18 |