| NPI | 1386762557 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MI 015510) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NY 050406) |
| Enumeration Date | 2007-03-27 |
| Last Update Date | 2023-01-27 |