| NPI | 1053398842 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: NC 9351) |
| Additional Taxonomies | 122300000X Dentist (Licence: MD 13843) |
| 122300000X Dentist (Licence: NM DD3354) | |
| Enumeration Date | 2005-12-22 |
| Last Update Date | 2012-08-14 |