| NPI | 1275759953 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: OR D7965) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MI 18767) |
| Enumeration Date | 2007-04-18 |
| Last Update Date | 2022-02-01 |