| NPI | 1831276492 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: MI 2901017623) |
| Additional Taxonomies | 122300000X Dentist (Licence: IA DDS-07893) |
| Enumeration Date | 2006-11-01 |
| Last Update Date | 2022-03-23 |