| NPI | 1063500056 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: UT 9496943-9922) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: OR D7185) |
| Enumeration Date | 2006-10-11 |
| Last Update Date | 2017-02-03 |