| NPI | 1619025756 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: TX 16824) |
| Additional Taxonomies | 1223P0300X Dentist, Periodontics (Licence: MI 2901018013) |
| Enumeration Date | 2007-01-08 |
| Last Update Date | 2009-08-29 |