| NPI | 1083821680 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: PA PA-DS021711L) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS 021711L) |
| 122300000X Dentist (Licence: PA DP000596) | |
| Enumeration Date | 2007-05-16 |
| Last Update Date | 2009-07-01 |