| NPI | 1063510105 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NC 5809) |
| Additional Taxonomies | 1223E0200X Dentist, Endodontics (Licence: NY 5809) |
| Enumeration Date | 2006-09-20 |
| Last Update Date | 2008-03-05 |