| NPI | 1154584522 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: TN DS0000009381) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA 0401412203) |
| Enumeration Date | 2008-07-07 |
| Last Update Date | 2013-01-09 |