| NPI | 1013148105 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 29172) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MN D12678) |
| Enumeration Date | 2009-08-06 |
| Last Update Date | 2014-01-24 |