| NPI | 1174580815 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223D0004X Dentist, Dentist Anesthesiologist Speciality (Licence: PA DA031803) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: SC 3504) |
| 1223G0001X Dentist, General Practice (Licence: PA DS041643) | |
| Enumeration Date | 2006-04-27 |
| Last Update Date | 2018-09-05 |