| NPI | 1164738365 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NV LL-226-10) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CO 10419) |
| Enumeration Date | 2010-08-25 |
| Last Update Date | 2011-07-05 |