| NPI | 1184791865 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MO 012952) |
| Additional Taxonomies | 1223P0221X Dentist, Pediatric Dentistry (Licence: WA 7872) |
| Enumeration Date | 2006-11-29 |
| Last Update Date | 2007-07-08 |