| NPI | 1083840250 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: GA DN014170) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MN D12659) |
| Enumeration Date | 2009-06-02 |
| Last Update Date | 2016-12-19 |