| NPI | 1003947615 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NC 9269) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: SC 6983) |
| 1223G0001X Dentist, General Practice (Licence: IA 08425) | |
| Enumeration Date | 2007-03-07 |
| Last Update Date | 2018-08-14 |