| NPI | 1811601560 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist Periodontics (Licence: MI 2951000835) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 40090) |
| Enumeration Date | 2023-01-09 |
| Last Update Date | 2025-04-15 |