| NPI | 1205031986 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: IA 08982) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: ID D4074) |
| 1223G0001X Dentist, General Practice (Licence: CO DEN-9674) | |
| Enumeration Date | 2007-06-20 |
| Last Update Date | 2020-02-12 |