| NPI | 1013062884 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CT 6283) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CT 6283) |
| Enumeration Date | 2007-01-24 |
| Last Update Date | 2015-05-14 |