| NPI | 1194210641 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: OR D11013) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MI 2901022735) |
| Enumeration Date | 2018-06-27 |
| Last Update Date | 2021-02-03 |