| NPI | 1174772016 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NM DD3444) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: UT 7106444-9922) |
| Enumeration Date | 2008-09-16 |
| Last Update Date | 2013-01-28 |