| NPI | 1669717344 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MI 2901015738) |
| Additional Taxonomies | 122300000X Dentist (Licence: OH 30-01-8652) |
| Enumeration Date | 2012-12-06 |
| Last Update Date | 2012-12-06 |