| NPI | 1548423015 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MI 2901022201) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MI 5691005799) |
| 363AM0700X Physician Assistant, Medical (Licence: WY TL447) | |
| Enumeration Date | 2008-07-05 |
| Last Update Date | 2022-07-21 |