| NPI | 1851554299 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MI 2901019958) |
| Additional Taxonomies | 122300000X Dentist (Licence: OK GPR.Don't.Have.Licen) |
| Enumeration Date | 2008-07-07 |
| Last Update Date | 2010-05-07 |