| NPI | 1154584787 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NC 9415) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 24409) |
| 1223G0001X Dentist, General Practice (Licence: TN 9207) | |
| Enumeration Date | 2008-07-03 |
| Last Update Date | 2014-01-29 |