| NPI | 1104247295 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: UT 13577) |
| Additional Taxonomies | 122300000X Dentist (Licence: AZ D01899) |
| 122300000X Dentist (Licence: CA 23841) | |
| 122300000X Dentist (Licence: CO 501) | |
| Enumeration Date | 2013-12-17 |
| Last Update Date | 2013-12-17 |