| NPI | 1720485063 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MI 2901021442) |
| Additional Taxonomies | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: MI 2901021442) |
| Enumeration Date | 2014-12-02 |
| Last Update Date | 2014-12-02 |