| NPI | 1114396751 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: AZ D009505) |
| Additional Taxonomies | 122300000X Dentist (Licence: CO DEN.00202672) |
| Enumeration Date | 2015-09-23 |
| Last Update Date | 2016-12-22 |