| NPI | 1730269069 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: MN 8276) |
| Additional Taxonomies | 1223P0300X Dentist, Periodontics (Licence: WI 5002088-015) |
| Enumeration Date | 2006-10-17 |
| Last Update Date | 2007-07-08 |