| NPI | 1013034289 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CO 9643) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NY 053073) |
| Enumeration Date | 2007-03-23 |
| Last Update Date | 2012-11-16 |