| NPI | 1972838415 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: TX 28649) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: MI 2901020107) |
| Enumeration Date | 2009-10-15 |
| Last Update Date | 2024-02-20 |