| NPI | 1659615466 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MI 14805) |
| Additional Taxonomies | 261QD0000X Clinic/Center, Dental |
| Enumeration Date | 2012-11-16 |
| Last Update Date | 2012-11-16 |