| NPI | 1861693491 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: MN D12733) |
| Additional Taxonomies | 1223P0300X Dentist, Periodontics (Licence: IA 08416) |
| Enumeration Date | 2007-05-30 |
| Last Update Date | 2015-06-24 |