| NPI | 1053744136 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CO 00202061) |
| Additional Taxonomies | 122300000X Dentist (Licence: MO 2013022866) |
| 122300000X Dentist (Licence: IL 019029483) | |
| Enumeration Date | 2013-08-13 |
| Last Update Date | 2014-02-06 |