| NPI | 1720139728 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: PA DS036734) |
| Additional Taxonomies | 1223P0300X Dentist, Periodontics (Licence: PA DS036734) |
| 1223P0300X Dentist, Periodontics (Licence: MI 2901018790) | |
| Enumeration Date | 2007-01-16 |
| Last Update Date | 2009-05-15 |