| NPI | 1053472613 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: GA DN013630) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA 0401411757) |
| 122300000X Dentist (Licence: GA DN013630) | |
| 1223G0001X Dentist, General Practice (Licence: PA DS036872) | |
| Enumeration Date | 2006-12-13 |
| Last Update Date | 2016-06-13 |