| NPI | 1104054550 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223E0200X Dentist, Endodontics (Licence: SC 7144) |
| Additional Taxonomies | 122300000X Dentist (Licence: WV 3875) |
| 1223E0200X Dentist, Endodontics (Licence: NC 9190) | |
| Enumeration Date | 2009-06-24 |
| Last Update Date | 2013-01-22 |