| NPI | 1023170883 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: AZ 6661) |
| Additional Taxonomies | 122300000X Dentist (Licence: AZ 6661) |
| Enumeration Date | 2006-12-15 |
| Last Update Date | 2015-07-02 |