| NPI | 1659798866 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: MN D13754) |
| Additional Taxonomies | 1223P0221X Dentist, Pediatric Dentistry (Licence: OH 30-024262) |
| Enumeration Date | 2014-03-25 |
| Last Update Date | 2016-08-25 |