| NPI | 1124305057 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: GA DN014311) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: WI 6842-15) |
| Enumeration Date | 2011-11-06 |
| Last Update Date | 2020-04-05 |