| NPI | 1114206109 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: WI 1002048) |
| Additional Taxonomies | 122300000X Dentist (Licence: IL 019.028557) |
| Enumeration Date | 2011-08-09 |
| Last Update Date | 2019-05-15 |