| NPI | 1790876977 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MI 2901016085) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MI 16085) |
| Enumeration Date | 2006-09-27 |
| Last Update Date | 2022-05-06 |