| NPI | 1306992649 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MI 2901013148) |
| Additional Taxonomies | 1223P0300X Dentist, Periodontics (Licence: MI 29010131481365022) |
| Enumeration Date | 2007-01-27 |
| Last Update Date | 2007-07-08 |