| NPI | 1780166025 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MI 2901022797) |
| Additional Taxonomies | 122300000X Dentist (Licence: AZ D010167) |
| Enumeration Date | 2018-09-04 |
| Last Update Date | 2021-09-07 |