| NPI | 1356577613 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: VA 0401414685) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 2901020024) |
| Enumeration Date | 2009-06-01 |
| Last Update Date | 2020-10-20 |