| NPI | 1245331164 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MI 2901013225) |
| Additional Taxonomies | 332B00000X Durable Medical Equipment & Medical Supplies |
| Enumeration Date | 2006-09-25 |
| Last Update Date | 2019-12-27 |