| NPI | 1023217593 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NC 150620) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA 0401412033) |
| Enumeration Date | 2007-07-16 |
| Last Update Date | 2015-02-17 |