| NPI | 1417008574 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MI 2952000782) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MI 15618) |
| Enumeration Date | 2007-01-16 |
| Last Update Date | 2021-12-16 |