| NPI | 1669463162 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE00010774) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 2901018654) |
| Enumeration Date | 2005-11-02 |
| Last Update Date | 2011-02-09 |