| NPI | 1164838579 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: IL 019.029888) |
| Additional Taxonomies | 122300000X Dentist (Licence: WI 7278-15) |
| Enumeration Date | 2014-07-07 |
| Last Update Date | 2014-07-07 |