| NPI | 1619091790 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MI 2901011135) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MI 2901011135) |
| Enumeration Date | 2007-03-16 |
| Last Update Date | 2007-07-08 |