| NPI | 1003005547 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: VA 0401411673) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA 0401411673) |
| Enumeration Date | 2007-10-22 |
| Last Update Date | 2011-02-15 |