| NPI | 1255778205 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CO 00202211) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 2901020977) |
| Enumeration Date | 2013-05-31 |
| Last Update Date | 2019-03-06 |