| NPI | 1619260494 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: MI 2901020381) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 2901020381) |
| Enumeration Date | 2011-05-26 |
| Last Update Date | 2015-08-27 |