| NPI | 1174613806 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: GA DN015734) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AL PA-483) |
| Enumeration Date | 2006-10-13 |
| Last Update Date | 2018-08-11 |