| NPI | 1063555043 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CO 10703) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NV 5133) |
| 122300000X Dentist (Licence: NV 5133) | |
| Enumeration Date | 2007-02-15 |
| Last Update Date | 2014-01-08 |