| NPI | 1659357846 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: MI ID # 2901015600) |
| Additional Taxonomies | 1223P0700X Dentist, Prosthodontics (Licence: MI 2901015600) |
| Enumeration Date | 2005-12-20 |
| Last Update Date | 2014-07-29 |