| NPI | 1104966753 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TN DS007494) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: GA DN012874) |
| Enumeration Date | 2007-02-06 |
| Last Update Date | 2007-07-08 |