| NPI | 1619358397 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WI 1001134 - 15) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MN D13938) |
| Enumeration Date | 2015-06-18 |
| Last Update Date | 2019-06-13 |