| NPI | 1194081182 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 29449) |
| Additional Taxonomies | 122300000X Dentist (Licence: IL 019.028842) |
| Enumeration Date | 2012-04-04 |
| Last Update Date | 2013-10-10 |