| NPI | 1487387437 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MN D14830) |
| Additional Taxonomies | 122300000X Dentist (Licence: WI 6001017-15) |
| Enumeration Date | 2022-07-07 |
| Last Update Date | 2026-03-24 |