| NPI | 1700018074 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MI 2901021322) |
| Additional Taxonomies | 122300000X Dentist (Licence: IA 08659) |
| Enumeration Date | 2009-08-19 |
| Last Update Date | 2023-10-17 |