| NPI | 1124513288 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NM DD4950) |
| Additional Taxonomies | 122300000X Dentist (Licence: CO DEN.00203669) |
| Enumeration Date | 2018-06-29 |
| Last Update Date | 2018-11-09 |