| NPI | 1194948539 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: VA 0401413328) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA 21651) |
| 122300000X Dentist (Licence: CA 58166) | |
| Enumeration Date | 2007-04-11 |
| Last Update Date | 2011-09-26 |