| NPI | 1376762468 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: MI 2901013827) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: MI 5315137548) |
| Enumeration Date | 2007-04-25 |
| Last Update Date | 2021-09-08 |