| NPI | 1053391797 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: KS 6993) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: AK 117592) |
| 1223G0001X Dentist, General Practice (Licence: CO 7367) | |
| 1223G0001X Dentist, General Practice (Licence: TX 14581) | |
| Enumeration Date | 2006-01-19 |
| Last Update Date | 2019-10-18 |