| NPI | 1558408930 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MN D8160) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WI 5001509-15) |
| Enumeration Date | 2007-02-01 |
| Last Update Date | 2025-03-02 |