| NPI | 1053577130 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CO den.00202126) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WA DE60034302) |
| 122300000X Dentist (Licence: NM DD3475) | |
| Enumeration Date | 2008-07-29 |
| Last Update Date | 2013-12-19 |