| NPI | 1104963651 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: PA DS017950) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: PA DS035637) |
| 1223P0300X Dentist, Periodontics (Licence: PA DS02736L) | |
| Enumeration Date | 2007-01-31 |
| Last Update Date | 2007-07-08 |