| NPI | 1619289956 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MN R486) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: PA DS038356) |
| Enumeration Date | 2010-07-01 |
| Last Update Date | 2018-05-30 |