| NPI | 1679585467 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: FL DTP780) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 2901012237) |
| 122300000X Dentist (Licence: MI 29010012237) | |
| Enumeration Date | 2006-08-12 |
| Last Update Date | 2023-06-20 |