| NPI | 1811317142 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MO 2018032931) |
| Additional Taxonomies | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: MI 2901021748) |
| Enumeration Date | 2014-04-25 |
| Last Update Date | 2019-10-03 |