| NPI | 1194131557 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: AZ 9934) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 30205) |
| Enumeration Date | 2014-07-07 |
| Last Update Date | 2018-03-17 |