| NPI | 1598119273 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: MN D13705) |
| Additional Taxonomies | 122300000X Dentist (Licence: MN D13705) |
| Enumeration Date | 2016-04-19 |
| Last Update Date | 2021-08-05 |