| NPI | 1093955130 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 24394) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 0024394) |
| 122300000X Dentist (Licence: PA DS037601) | |
| Enumeration Date | 2009-03-03 |
| Last Update Date | 2015-04-23 |