| NPI | 1164512877 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NV GR4651T) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NE 6482) |
| Enumeration Date | 2006-10-13 |
| Last Update Date | 2007-07-08 |