| NPI | 1912254160 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: MN d13341) |
| Additional Taxonomies | 122300000X Dentist (Licence: NE 7009) |
| Enumeration Date | 2012-08-07 |
| Last Update Date | 2018-04-11 |