| NPI | 1912149956 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist Pediatric Dentistry (Licence: MI 2901020768) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 59000106) |
| Enumeration Date | 2009-04-06 |
| Last Update Date | 2012-08-14 |