| NPI | 1659589075 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: MI 2901019162) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 2901019162) |
| Enumeration Date | 2007-05-18 |
| Last Update Date | 2009-08-06 |