| NPI | 1194805291 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: ID D-5004) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: CA 52352) |
| Enumeration Date | 2006-10-16 |
| Last Update Date | 2020-06-11 |