| NPI | 1083841167 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CO DEN-9948) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WY 1270) |
| Enumeration Date | 2009-06-16 |
| Last Update Date | 2016-05-27 |