| NPI | 1245907070 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist Periodontics (Licence: MI 2901601126) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 2901601126) |
| Enumeration Date | 2021-08-28 |
| Last Update Date | 2021-10-21 |