| NPI | 1205217106 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: WI 1001078-15) |
| Additional Taxonomies | 122300000X Dentist (Licence: MN D13630) |
| Enumeration Date | 2015-06-16 |
| Last Update Date | 2016-03-08 |