| NPI | 1386619476 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MI 2901014245) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 14245) |
| Enumeration Date | 2006-02-22 |
| Last Update Date | 2015-02-12 |