| NPI | 1215627724 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: MI 2901602468) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 2901602468) |
| Enumeration Date | 2023-05-09 |
| Last Update Date | 2025-09-22 |