| NPI | 1902320286 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: MN D14111) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: WI 1001549) |
| Enumeration Date | 2017-07-28 |
| Last Update Date | 2019-07-22 |