| NPI | 1194070912 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NC 9358) |
| Additional Taxonomies | 122300000X Dentist (Licence: FL 20975) |
| Enumeration Date | 2012-07-18 |
| Last Update Date | 2016-08-31 |