| NPI | 1184913089 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: CO DEN-00201817) |
| Additional Taxonomies | 122300000X Dentist (Licence: MN D12903) |
| Enumeration Date | 2011-03-31 |
| Last Update Date | 2018-10-18 |