| NPI | 1356326029 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MN 12387) |
| Additional Taxonomies | 122300000X Dentist (Licence: NM DD2591) |
| Enumeration Date | 2005-12-14 |
| Last Update Date | 2008-07-23 |