| NPI | 1134476674 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: OR D10734) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: PA DS039288) |
| Enumeration Date | 2012-08-14 |
| Last Update Date | 2018-03-17 |