| NPI | 1083834576 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QD0000X Clinic/Center, Dental |
| Additional Taxonomies | 122300000X Dentist (Licence: WI 5131) |
| 1223G0001X Dentist, General Practice (Licence: WI 5131) | |
| Enumeration Date | 2007-04-26 |
| Last Update Date | 2013-10-03 |