| NPI | 1124258736 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: NV 6902) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 29610) |
| 122300000X Dentist (Licence: CA 57861) | |
| 122300000X Dentist (Licence: FL DN18605) | |
| Enumeration Date | 2009-07-16 |
| Last Update Date | 2019-10-22 |