| NPI | 1205149275 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NC 9061) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: PA DS039342) |
| Enumeration Date | 2010-07-20 |
| Last Update Date | 2019-03-20 |