| NPI | 1104276260 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: VA 0401415511) |
| Additional Taxonomies | 122300000X Dentist (Licence: NC intern) |
| Enumeration Date | 2016-06-20 |
| Last Update Date | 2018-08-17 |