| NPI | 1558621086 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223E0200X Dentist, Endodontics (Licence: MN D13634) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: PA DS039043) |
| Enumeration Date | 2012-05-17 |
| Last Update Date | 2016-08-09 |