| NPI | 1174603963 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: MD 13905) |
| Additional Taxonomies | 1223P0300X Dentist, Periodontics (Licence: WA DE00010389) |
| 1223P0300X Dentist, Periodontics (Licence: MI 2901018462) | |
| Enumeration Date | 2006-10-16 |
| Last Update Date | 2015-09-18 |