| NPI | 1265164818 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: MI 2901602693) |
| Additional Taxonomies | 122300000X Dentist (Licence: KY 10777) |
| Enumeration Date | 2022-06-30 |
| Last Update Date | 2025-08-22 |