| NPI | 1215087812 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NC 8478) |
| Additional Taxonomies | 122300000X Dentist (Licence: NC 260065) |
| 122300000X Dentist (Licence: MI 2901018995) | |
| Enumeration Date | 2007-01-12 |
| Last Update Date | 2020-03-02 |