| NPI | 1154696946 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: PA DS040355) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: PA DS040355) |
| Enumeration Date | 2012-03-13 |
| Last Update Date | 2021-03-07 |