| NPI | 1194098723 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NM DD4166) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 2901020710) |
| Enumeration Date | 2012-02-13 |
| Last Update Date | 2014-09-05 |