| NPI | 1164499109 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MS PRV-TP-107-04) |
| Additional Taxonomies | 122300000X Dentist (Licence: KY 4883) |
| Enumeration Date | 2006-03-08 |
| Last Update Date | 2007-07-08 |