| NPI | 1043308331 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: TX 18952) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 18952) |
| Enumeration Date | 2006-10-11 |
| Last Update Date | 2008-02-26 |