| NPI | 1003881905 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: PA DS024969L) |
| Additional Taxonomies | 122300000X Dentist (Licence: LA P-138) |
| Enumeration Date | 2006-02-22 |
| Last Update Date | 2012-11-05 |