| NPI | 1659561967 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MN D14102) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CA 55801) |
| Enumeration Date | 2007-08-01 |
| Last Update Date | 2019-02-27 |