| NPI | 1104017839 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NV 5642) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: OR D8953) |
| Enumeration Date | 2007-08-07 |
| Last Update Date | 2014-07-01 |