| NPI | 1134303738 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NC 6746) |
| Additional Taxonomies | 261QM1300X Clinic/Center, Multi-Specialty |
| 332B00000X Durable Medical Equipment & Medical Supplies | |
| Enumeration Date | 2007-12-19 |
| Last Update Date | 2021-09-29 |