| NPI | 1962698340 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X2210X Dentist, Orofacial Pain (Licence: MN D13340) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 58751) |
| 1223G0001X Dentist, General Practice (Licence: MN 13340) | |
| Enumeration Date | 2007-09-19 |
| Last Update Date | 2022-10-05 |