| NPI | 1114417060 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: PA DS041885) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: VA 0401416605) |
| Enumeration Date | 2018-05-16 |
| Last Update Date | 2019-07-02 |