| NPI | 1710052659 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MN 10703) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WY 998) |
| Enumeration Date | 2006-11-22 |
| Last Update Date | 2007-07-08 |