| NPI | 1073521993 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: NC 4010) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NY 0310591) |
| Enumeration Date | 2006-08-04 |
| Last Update Date | 2007-07-08 |