| NPI | 1326018508 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0008X Dentist, Oral and Maxillofacial Radiology (Licence: VA 0401008067) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI military exempt stat) |
| 1223G0001X Dentist, General Practice (Licence: VA 0401008067) | |
| Enumeration Date | 2006-01-23 |
| Last Update Date | 2019-08-02 |