| NPI | 1104892819 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CO 100973) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 8830) |
| Enumeration Date | 2006-02-23 |
| Last Update Date | 2007-07-08 |