| NPI | 1184905689 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 27389) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MI 2901020497) |
| Enumeration Date | 2011-08-29 |
| Last Update Date | 2021-01-28 |