| NPI | 1649282898 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MI 18650) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 24426) |
| Enumeration Date | 2006-08-13 |
| Last Update Date | 2016-09-11 |