| NPI | 1104921972 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: FL DN14288) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: FL DN14288) |
| 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: PR 2240) | |
| Enumeration Date | 2006-09-14 |
| Last Update Date | 2010-06-03 |