| NPI | 1174604110 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MT DEN-DEN-LIC-9751) |
| Additional Taxonomies | 122300000X Dentist (Licence: MN 10403) |
| Enumeration Date | 2006-10-18 |
| Last Update Date | 2025-01-29 |