| NPI | 1306836291 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: MN D11258) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MN D11258) |
| Enumeration Date | 2005-10-24 |
| Last Update Date | 2021-01-19 |