| NPI | 1508940107 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: MN 73063) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 56189) |
| 122300000X Dentist (Licence: MN D15051) | |
| 208D00000X General Practice (Licence: VA 0101276912) | |
| Enumeration Date | 2006-10-24 |
| Last Update Date | 2025-01-29 |