| NPI | 1912344284 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: ID 4903) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MN D13208) |
| Enumeration Date | 2013-05-28 |
| Last Update Date | 2019-02-06 |