| NPI | 1700871118 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: IN 12013438A) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MI 5601003571) |
| 363A00000X Physician Assistant (Licence: MI 5601003571) | |
| Enumeration Date | 2005-09-13 |
| Last Update Date | 2020-07-22 |