| NPI | 1003953316 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WY #1151) |
| Additional Taxonomies | 122300000X Dentist (Licence: WY 1511) |
| Enumeration Date | 2007-01-30 |
| Last Update Date | 2021-09-30 |