| NPI | 1407827512 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MI 2901020334) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 15878) |
| 1223G0001X Dentist, General Practice (Licence: CA 52527) | |
| Enumeration Date | 2006-01-27 |
| Last Update Date | 2011-07-25 |