| NPI | 1891958955 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 25166) |
| Additional Taxonomies | 122300000X Dentist (Licence: AZ D7550) |
| 1223G0001X Dentist General Practice (Licence: AZ D7550) | |
| 1223G0001X Dentist General Practice (Licence: MI 2901019826) | |
| Enumeration Date | 2008-07-08 |
| Last Update Date | 2020-09-24 |