| NPI | 1649426461 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: WI 6407-15) |
| Additional Taxonomies | 1223P0300X Dentist, Periodontics (Licence: MN D12223) |
| Enumeration Date | 2008-08-12 |
| Last Update Date | 2009-08-26 |