| NPI | 1609097765 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MI 2901015640) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 15640) |
| Enumeration Date | 2007-05-02 |
| Last Update Date | 2022-11-21 |