| NPI | 1912132333 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: CO 10713) |
| Additional Taxonomies | 122300000X Dentist (Licence: MN D12539) |
| 1223P0300X Dentist, Periodontics (Licence: MN D12539) | |
| Enumeration Date | 2009-05-29 |
| Last Update Date | 2012-07-05 |