| NPI | 1255851291 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist Pediatric Dentistry (Licence: MI 2901601455) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: KY 9940) |
| Enumeration Date | 2017-06-21 |
| Last Update Date | 2022-10-19 |