| NPI | 1003805730 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: ND 1900) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: ND 1900) |
| Enumeration Date | 2005-10-15 |
| Last Update Date | 2019-11-28 |