| NPI | 1619339629 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE61227375) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 2901021797) |
| Enumeration Date | 2016-03-28 |
| Last Update Date | 2022-02-24 |