| NPI | 1053467399 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MO 2002012097) |
| Additional Taxonomies | 1223D0001X Dentist, Dental Public Health (Licence: AR 3693) |
| Enumeration Date | 2007-01-27 |
| Last Update Date | 2012-10-17 |