| NPI | 1639373285 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MN D9510) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WI 3281WI) |
| Enumeration Date | 2007-06-14 |
| Last Update Date | 2016-04-26 |