| NPI | 1053416503 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: VA 0401410370) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DE00008454) |
| Enumeration Date | 2006-09-13 |
| Last Update Date | 2007-07-08 |