| NPI | 1487271615 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MI 2901600887) |
| Additional Taxonomies | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: OH 30.026233) |
| Enumeration Date | 2020-07-04 |
| Last Update Date | 2021-08-01 |