| NPI | 1568573327 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: MN 11840) |
| Additional Taxonomies | 1223P0300X Dentist Periodontics (Licence: CA 58222) |
| Enumeration Date | 2006-08-31 |
| Last Update Date | 2012-08-28 |