| NPI | 1356412167 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 26264) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MI 2901019326) |
| Enumeration Date | 2006-11-13 |
| Last Update Date | 2013-12-12 |