| NPI | 1104075274 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: VA 0401412293) |
| Additional Taxonomies | 122300000X Dentist (Licence: DC DEN1000791) |
| Enumeration Date | 2008-09-15 |
| Last Update Date | 2016-02-11 |