| NPI | 1972080232 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MA DN1858237) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 2901022728) |
| Enumeration Date | 2018-07-19 |
| Last Update Date | 2019-06-21 |