| NPI | 1194893685 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MI 012350) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: MI 2901012350) |
| Enumeration Date | 2006-12-01 |
| Last Update Date | 2015-11-04 |