| NPI | 1144437633 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: SC ID0012) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA 0401008161) |
| Enumeration Date | 2007-05-16 |
| Last Update Date | 2007-07-08 |