| NPI | 1710432885 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CO DEN.00202963) |
| Additional Taxonomies | 122300000X Dentist (Licence: MN D13731) |
| Enumeration Date | 2016-08-18 |
| Last Update Date | 2016-08-18 |