| NPI | 1780255844 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: MN D14624) |
| Additional Taxonomies | 122300000X Dentist (Licence: MN D14624) |
| Enumeration Date | 2021-07-08 |
| Last Update Date | 2025-05-14 |