| NPI | 1982901674 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MI 2901020594) |
| Additional Taxonomies | 122300000X Dentist (Licence: WI 6647-15) |
| Enumeration Date | 2011-02-16 |
| Last Update Date | 2021-10-09 |