| NPI | 1952632457 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MI 2901020144) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MI 2901020144) |
| Enumeration Date | 2010-01-22 |
| Last Update Date | 2016-08-01 |