| NPI | 1013995703 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: AZ 7164) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MT 2123) |
| Enumeration Date | 2006-01-04 |
| Last Update Date | 2011-06-13 |