| NPI | 1851510911 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MN 11813) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WI 6061) |
| Enumeration Date | 2007-04-25 |
| Last Update Date | 2007-10-22 |