| NPI | 1992790885 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: KY 10663) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MI 2901018601) |
| Enumeration Date | 2005-09-16 |
| Last Update Date | 2021-06-24 |