| NPI | 1003895368 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: GA DN01311) |
| Additional Taxonomies | 1223P0700X Dentist Prosthodontics (Licence: GA DN013111) |
| Enumeration Date | 2006-01-13 |
| Last Update Date | 2012-05-11 |