| NPI | 1659865020 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MI 2901600389) |
| Additional Taxonomies | 122300000X Dentist (Licence: MN D14060) |
| Enumeration Date | 2018-06-19 |
| Last Update Date | 2020-02-07 |