| NPI | 1124348529 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: AZ 8100) |
| Additional Taxonomies | 122300000X Dentist (Licence: NM DD3298) |
| Enumeration Date | 2010-06-08 |
| Last Update Date | 2013-12-10 |