| NPI | 1629239132 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MI 2901019627) |
| Additional Taxonomies | 1223P0700X Dentist, Prosthodontics (Licence: MI 2901019627) |
| Enumeration Date | 2008-06-18 |
| Last Update Date | 2018-04-16 |