| NPI | 1003266164 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: CO DEN.00203512) |
| Additional Taxonomies | 122300000X Dentist (Licence: NM DD4531) |
| Enumeration Date | 2016-06-20 |
| Last Update Date | 2019-06-13 |