| NPI | 1255577409 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MI 2901019741) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 50441) |
| 1223G0001X Dentist General Practice (Licence: MI 2901019741) | |
| Enumeration Date | 2008-12-18 |
| Last Update Date | 2019-04-23 |