| NPI | 1477753283 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: CO 10310) |
| Additional Taxonomies | 1223P0700X Dentist, Prosthodontics (Licence: MN R318) |
| Enumeration Date | 2007-07-19 |
| Last Update Date | 2012-03-15 |