| NPI | 1942251400 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MN D9025) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MI 2901012136) |
| 1223G0001X Dentist, General Practice (Licence: WI 6127-015) | |
| Enumeration Date | 2006-05-12 |
| Last Update Date | 2014-10-24 |