| NPI | 1306053996 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: SD D0802) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MI 2901018684) |
| Enumeration Date | 2007-05-16 |
| Last Update Date | 2010-09-09 |