| NPI | 1174869515 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: CA 63881) |
| Additional Taxonomies | 1223P0300X Dentist, Periodontics (Licence: MI 2901020820) |
| Enumeration Date | 2012-12-12 |
| Last Update Date | 2017-01-24 |