| NPI | 1760644132 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: MI 2901019565) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: SC 4469) |
| 1223G0001X Dentist General Practice (Licence: MI 2901019565) | |
| 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: MN S47) | |
| Enumeration Date | 2008-06-27 |
| Last Update Date | 2015-08-22 |