| NPI | 1245547397 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: MI 2901020244) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 2901020244) |
| Enumeration Date | 2010-09-10 |
| Last Update Date | 2018-03-17 |