| NPI | 1215598412 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: PA DS043437) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 2901600206) |
| 1223G0001X Dentist, General Practice (Licence: MI 2901600206) | |
| Enumeration Date | 2019-06-27 |
| Last Update Date | 2022-02-07 |