| NPI | 1780849547 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: AK 175) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MI 2901019863) |
| Enumeration Date | 2008-07-22 |
| Last Update Date | 2011-06-30 |