| NPI | 1861948796 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: PA DS044944) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 2901022072) |
| Enumeration Date | 2016-08-31 |
| Last Update Date | 2025-07-01 |