| NPI | 1801052915 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: IA 08702) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MN D12600) |
| 122300000X Dentist (Licence: MN D12600) | |
| Enumeration Date | 2008-07-29 |
| Last Update Date | 2010-10-04 |