| NPI | 1164787453 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NM DD3698) |
| Additional Taxonomies | 122300000X Dentist (Licence: NM DD3698) |
| Enumeration Date | 2012-07-12 |
| Last Update Date | 2016-06-02 |