| NPI | 1124127626 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NC 10539) |
| Additional Taxonomies | 332B00000X Durable Medical Equipment & Medical Supplies (Licence: NC 10539) |
| Enumeration Date | 2006-09-21 |
| Last Update Date | 2019-12-09 |