| NPI | 1174658157 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist Periodontics (Licence: CO 10746) |
| Additional Taxonomies | 1223P0300X Dentist Periodontics (Licence: FL DN16067) |
| Enumeration Date | 2007-02-22 |
| Last Update Date | 2020-04-07 |