| NPI | 1013299189 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: NC 9631) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 27405) |
| Enumeration Date | 2011-09-15 |
| Last Update Date | 2016-06-13 |