| NPI | 1841850278 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: NM DD5582) |
| Additional Taxonomies | 122300000X Dentist (Licence: MN D14308) |
| Enumeration Date | 2019-06-18 |
| Last Update Date | 2022-07-13 |