| NPI | 1104909431 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NC 7562) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: PA DS027256L) |
| Enumeration Date | 2006-10-23 |
| Last Update Date | 2007-07-08 |