| NPI | 1891212783 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 34670) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MI 2901022419) |
| Enumeration Date | 2017-08-23 |
| Last Update Date | 2019-11-18 |