| NPI | 1164438818 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: NM DD2023) |
| Additional Taxonomies | 122300000X Dentist (Licence: CO 7096) |
| 122300000X Dentist (Licence: MD 12081) | |
| Enumeration Date | 2006-08-01 |
| Last Update Date | 2007-07-08 |