| NPI | 1083926356 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: AZ D010080) |
| Additional Taxonomies | 122300000X Dentist (Licence: CO 10370) |
| 122300000X Dentist (Licence: IA 08719) | |
| Enumeration Date | 2010-07-02 |
| Last Update Date | 2019-03-05 |