| NPI | 1013016104 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: AZ D6926) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: MS 3279-03) |
| Enumeration Date | 2006-09-22 |
| Last Update Date | 2008-06-28 |