| NPI | 1336642636 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MI 2901022482) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: VA 040415918) |
| Enumeration Date | 2018-03-13 |
| Last Update Date | 2021-04-12 |