| NPI | 1568655041 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MI 2901019700) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 2901019700) |
| Enumeration Date | 2007-08-20 |
| Last Update Date | 2019-01-05 |