| NPI | 1518453059 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MI 2901600407) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: PA DS041818) |
| Enumeration Date | 2018-07-09 |
| Last Update Date | 2022-03-16 |