| NPI | 1104912070 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WY 1352) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: AZ 5845) |
| 1223G0001X Dentist, General Practice (Licence: ID D4036) | |
| Enumeration Date | 2006-10-05 |
| Last Update Date | 2013-07-17 |