| NPI | 1679596472 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MI 11083) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: MI 11083) |
| Enumeration Date | 2006-07-25 |
| Last Update Date | 2012-04-20 |