| NPI | 1518338037 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MI 2901601094) |
| Additional Taxonomies | 122300000X Dentist (Licence: MD D87259) |
| Enumeration Date | 2015-10-09 |
| Last Update Date | 2021-12-06 |