| NPI | 1205811320 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: LA 5834) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NY 049744) |
| Enumeration Date | 2005-12-13 |
| Last Update Date | 2020-07-06 |