| NPI | 1063785905 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CT 010670) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS038942) |
| Enumeration Date | 2012-02-22 |
| Last Update Date | 2012-02-22 |