| NPI | 1083055974 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: NC 9861) |
| Additional Taxonomies | 122300000X Dentist (Licence: WV 4065) |
| Enumeration Date | 2013-07-09 |
| Last Update Date | 2015-10-30 |