| NPI | 1831336262 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MI 2952000477) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA DF10515) |
| Enumeration Date | 2009-01-07 |
| Last Update Date | 2021-10-22 |