| NPI | 1124186762 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: GA DN013659) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA 0401410189) |
| Enumeration Date | 2006-12-05 |
| Last Update Date | 2011-02-10 |