| NPI | 1265844807 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NM DD4403) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 2901021257) |
| Enumeration Date | 2014-06-02 |
| Last Update Date | 2020-03-02 |