| NPI | 1154448629 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: SC 3201) |
| Additional Taxonomies | 122300000X Dentist (Licence: KY 6817) |
| 1223P0300X Dentist, Periodontics (Licence: FL DN13450) | |
| Enumeration Date | 2007-03-22 |
| Last Update Date | 2007-07-08 |