| NPI | 1114056561 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: WI 5929) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: LA 2628) |
| Enumeration Date | 2007-03-03 |
| Last Update Date | 2007-07-08 |