| NPI | 1003225558 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: PA DS039522) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS039522) |
| Enumeration Date | 2014-08-08 |
| Last Update Date | 2016-08-20 |