| NPI | 1013011451 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: ND 1974) |
| Additional Taxonomies | 122300000X Dentist (Licence: WI 5945-015) |
| 122300000X Dentist (Licence: MN D12127) | |
| Enumeration Date | 2006-09-07 |
| Last Update Date | 2014-12-01 |