| NPI | 1043658610 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: OR D11002) |
| Additional Taxonomies | 122300000X Dentist (Licence: MO 2013016377) |
| 122300000X Dentist (Licence: KS 61300) | |
| 1223G0001X Dentist, General Practice (Licence: NM DD4461) | |
| Enumeration Date | 2013-06-05 |
| Last Update Date | 2019-05-01 |