| NPI | 1336406800 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: MN D13128) |
| Additional Taxonomies | 122300000X Dentist (Licence: MN D13128) |
| Enumeration Date | 2012-04-20 |
| Last Update Date | 2022-07-25 |