| NPI | 1104155902 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: GA DN014918) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: FL DN18865) |
| Enumeration Date | 2009-12-08 |
| Last Update Date | 2015-07-09 |