| NPI | 1366843237 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MI 2901600359) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS040138) |
| Enumeration Date | 2014-09-10 |
| Last Update Date | 2023-02-09 |