| NPI | 1881124212 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: TX 36702) |
| Additional Taxonomies | 122300000X Dentist (Licence: MN R689) |
| Enumeration Date | 2017-06-18 |
| Last Update Date | 2023-07-18 |