| NPI | 1245903905 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist Periodontics (Licence: MI 2901601082) |
| Additional Taxonomies | 1223P0300X Dentist Periodontics (Licence: MI 2901601082APP21) |
| Enumeration Date | 2021-07-28 |
| Last Update Date | 2021-12-14 |