| NPI | 1073042206 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: CO 00203786) |
| Additional Taxonomies | 122300000X Dentist (Licence: AZ D009758) |
| Enumeration Date | 2017-06-10 |
| Last Update Date | 2018-12-06 |