| NPI | 1770844268 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA 62554) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MI 2901020667) |
| Enumeration Date | 2012-05-31 |
| Last Update Date | 2017-05-10 |