| NPI | 1770505257 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MN D13506) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MN FF42) |
| 1223G0001X Dentist, General Practice (Licence: NY 042440) | |
| Enumeration Date | 2006-07-24 |
| Last Update Date | 2023-08-21 |