| NPI | 1205212875 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CO DEN.00202901) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 058103) |
| Enumeration Date | 2015-08-06 |
| Last Update Date | 2021-02-08 |