| NPI | 1700171774 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MI 2901021476) |
| Additional Taxonomies | 122300000X Dentist (Licence: IL 019.028956) |
| 122300000X Dentist (Licence: OH 30-02-3894) | |
| Enumeration Date | 2011-06-17 |
| Last Update Date | 2015-07-09 |