| NPI | 1912162645 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MI 2901019873) |
| Additional Taxonomies | 122300000X Dentist (Licence: IL 019028132) |
| Enumeration Date | 2008-07-22 |
| Last Update Date | 2012-11-27 |