| NPI | 1124207444 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: AZ D10967) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 56249) |
| Enumeration Date | 2007-11-02 |
| Last Update Date | 2022-10-24 |