| NPI | 1982213641 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MI 2901600889) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: AZ D010778) |
| Enumeration Date | 2020-07-29 |
| Last Update Date | 2021-06-01 |