| NPI | 1811347867 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: MN D13650) |
| Additional Taxonomies | 122300000X Dentist (Licence: MN 13650) |
| Enumeration Date | 2016-06-20 |
| Last Update Date | 2018-08-14 |