| NPI | 1528590783 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: MI 2952000770) |
| Additional Taxonomies | 1223P0300X Dentist, Periodontics (Licence: MA DL13096) |
| Enumeration Date | 2017-03-28 |
| Last Update Date | 2021-09-27 |