| NPI | 1326161605 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist Periodontics (Licence: KS 60867) |
| Additional Taxonomies | 122300000X Dentist (Licence: MO 2006025630) |
| 1223P0300X Dentist Periodontics (Licence: MO 2006025630) | |
| 1223P0300X Dentist Periodontics (Licence: WI 6644-015) | |
| Enumeration Date | 2007-04-09 |
| Last Update Date | 2019-01-03 |