| NPI | 1851320121 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: MN D11500) |
| Additional Taxonomies | 122300000X Dentist (Licence: NM DD199) |
| Enumeration Date | 2006-06-30 |
| Last Update Date | 2016-12-25 |