| NPI | 1164575676 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: WY 1214) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: SD M816) |
| Enumeration Date | 2007-01-19 |
| Last Update Date | 2015-06-16 |