| NPI | 1164797114 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: AL 6031) |
| Additional Taxonomies | 122300000X Dentist (Licence: LA 6325) |
| 1223G0001X Dentist, General Practice (Licence: MS 3650-12) | |
| Enumeration Date | 2012-03-08 |
| Last Update Date | 2017-03-23 |