| NPI | 1104963750 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: FL DN 17043) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: CA 56731) |
| Enumeration Date | 2007-01-31 |
| Last Update Date | 2020-07-15 |