| NPI | 1003093717 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 25235) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CO 8594) |
| Enumeration Date | 2008-01-24 |
| Last Update Date | 2010-12-09 |