| NPI | 1194735563 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CT 009537) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: RI DEN02733) |
| Enumeration Date | 2006-08-09 |
| Last Update Date | 2016-03-14 |