| NPI | 1184770448 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: OR D8524) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 24519) |
| Enumeration Date | 2007-01-26 |
| Last Update Date | 2014-01-15 |