| NPI | 1104996941 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: ND 1843) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: MN 1562357) |
| Enumeration Date | 2006-11-09 |
| Last Update Date | 2007-07-08 |