| NPI | 1972679066 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MN D8879) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CO 105054) |
| 1223G0001X Dentist, General Practice (Licence: IA 06752) | |
| 1223G0001X Dentist, General Practice (Licence: WI 2893015) | |
| Enumeration Date | 2006-11-28 |
| Last Update Date | 2007-07-08 |