| NPI | 1982902490 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MI 2952000449) |
| Additional Taxonomies | 1223P0700X Dentist, Prosthodontics (Licence: NC 0108) |
| Enumeration Date | 2011-03-08 |
| Last Update Date | 2022-03-31 |