| NPI | 1063583672 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: PA DS035810) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: CA 55046) |
| Enumeration Date | 2006-11-13 |
| Last Update Date | 2009-12-17 |