| NPI | 1619969102 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: VA 0401008188) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MI 011857) |
| 1223G0001X Dentist, General Practice (Licence: CA 28079) | |
| Enumeration Date | 2005-08-19 |
| Last Update Date | 2011-11-22 |