| NPI | 1457670762 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MN D14835) |
| Additional Taxonomies | 122300000X Dentist (Licence: ND 2158) |
| 1223G0001X Dentist, General Practice (Licence: SD 271) | |
| Enumeration Date | 2010-05-26 |
| Last Update Date | 2023-07-31 |