| NPI | 1548309644 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MI 2901019702) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 22687) |
| 1223D0001X Dentist, Dental Public Health (Licence: MI 2901019702) | |
| Enumeration Date | 2007-02-05 |
| Last Update Date | 2022-01-25 |