| NPI | 1285363374 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MI 2901601323) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 2901601323APP22) |
| Enumeration Date | 2022-06-06 |
| Last Update Date | 2022-06-06 |