| NPI | 1124394069 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: NV 6598) |
| Additional Taxonomies | 122300000X Dentist (Licence: ME DEN4310) |
| 1223G0001X Dentist, General Practice (Licence: TX 29704) | |
| Enumeration Date | 2012-03-26 |
| Last Update Date | 2015-09-24 |