| NPI | 1740610245 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: VA 0401418624) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 2901021192) |
| Enumeration Date | 2013-11-19 |
| Last Update Date | 2026-06-15 |