| NPI | 1790749554 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: AZ D008496) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MI 2901018708) |
| Enumeration Date | 2006-04-17 |
| Last Update Date | 2023-08-29 |