| NPI | 1063574879 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: DC 3164) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MD 6056) |
| Enumeration Date | 2006-12-15 |
| Last Update Date | 2007-07-08 |