| NPI | 1346405883 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: TX 26702) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MI 2901019796) |
| 1223P0300X Dentist, Periodontics (Licence: MI 2901019796) | |
| Enumeration Date | 2008-07-24 |
| Last Update Date | 2014-11-12 |