| NPI | 1164412706 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: ID D4231) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NM DD2644) |
| Enumeration Date | 2005-10-25 |
| Last Update Date | 2024-10-16 |