| NPI | 1164734372 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CT 10476) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: PA DS038384) |
| Enumeration Date | 2010-07-06 |
| Last Update Date | 2014-07-20 |