| NPI | 1265556468 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MI 2901018557) |
| Additional Taxonomies | 1223P0221X Dentist, Pediatric Dentistry (Licence: MI 2901018557) |
| Enumeration Date | 2007-03-16 |
| Last Update Date | 2007-07-09 |