| NPI | 1598996068 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: NY 063008) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 2901019712) |
| Enumeration Date | 2009-08-01 |
| Last Update Date | 2023-03-22 |