| NPI | 1174166821 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: MI 2952000778) |
| Additional Taxonomies | 1223P0300X Dentist, Periodontics (Licence: KY 10186) |
| Enumeration Date | 2019-10-25 |
| Last Update Date | 2021-12-10 |