| NPI | 1124123641 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: OR D10756) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: GA 10130) |
| Enumeration Date | 2006-09-13 |
| Last Update Date | 2019-02-26 |