| NPI | 1154492601 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WY 1397) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: OK 5796) |
| Enumeration Date | 2006-11-13 |
| Last Update Date | 2015-08-14 |