| NPI | 1922104413 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MI 13513) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 24302) |
| Enumeration Date | 2006-09-15 |
| Last Update Date | 2015-11-18 |