| NPI | 1548538416 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MN 10218) |
| Additional Taxonomies | 261QD0000X Clinic/Center, Dental (Licence: AL 6491) |
| Enumeration Date | 2011-12-07 |
| Last Update Date | 2018-09-28 |