| NPI | 1235101627 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MN D10221) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CO D6550) |
| 1223G0001X Dentist, General Practice (Licence: CA 33809) | |
| Enumeration Date | 2006-02-02 |
| Last Update Date | 2022-07-21 |