| NPI | 1174703219 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: OR d9198) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WY 1181) |
| Enumeration Date | 2007-11-06 |
| Last Update Date | 2013-03-22 |