| NPI | 1831684539 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MN D14826) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: PA DS041719) |
| Enumeration Date | 2018-06-25 |
| Last Update Date | 2022-10-05 |