| NPI | 1962929497 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: IA FAC-40202) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 2901021445) |
| 1223P0300X Dentist, Periodontics (Licence: MI 2901021445) | |
| Enumeration Date | 2017-08-25 |
| Last Update Date | 2021-08-30 |