| NPI | 1104989847 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: SC 2797) |
| Additional Taxonomies | 1223P0300X Dentist, Periodontics (Licence: SC 345) |
| Enumeration Date | 2006-12-17 |
| Last Update Date | 2007-07-08 |