| NPI | 1891011748 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: MN D12791) |
| Additional Taxonomies | 282N00000X General Acute Care Hospital (Licence: MN D12791) |
| Enumeration Date | 2010-04-18 |
| Last Update Date | 2012-04-27 |