| NPI | 1104915040 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: FL DN21053) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA 0401411606) |
| Enumeration Date | 2006-10-11 |
| Last Update Date | 2016-10-04 |