| NPI | 1164779294 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: PA DS039289) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS039289) |
| Enumeration Date | 2012-08-08 |
| Last Update Date | 2016-07-26 |