| NPI | 1790341048 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: MN D14849) |
| Additional Taxonomies | 1223P0300X Dentist, Periodontics (Licence: WI 6001151-15) |
| Enumeration Date | 2019-05-13 |
| Last Update Date | 2025-09-08 |