| NPI | 1033523642 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: VA 0401415354) |
| Additional Taxonomies | 122300000X Dentist (Licence: OH 3423) |
| Enumeration Date | 2014-06-12 |
| Last Update Date | 2016-10-01 |