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 |