| NPI | 1114997160 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TN DS0000008486) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MO 013843) |
| 1223G0001X Dentist, General Practice (Licence: VA 0401008150) | |
| Enumeration Date | 2006-01-24 |
| Last Update Date | 2009-04-08 |