| NPI | 1104829118 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: CO 8155) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: WY 1067) |
| Enumeration Date | 2005-05-23 |
| Last Update Date | 2021-10-26 |