| NPI | 1346498722 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NM 1629) |
| Additional Taxonomies | 332BC3200X Durable Medical Equipment & Medical Supplies, Customized Equipment (Licence: NM DD1629) |
| Enumeration Date | 2008-08-28 |
| Last Update Date | 2021-06-02 |