| NPI | 1205824695 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MO 2013004572) |
| Additional Taxonomies | 122300000X Dentist (Licence: NE 5826) |
| 1223G0001X Dentist, General Practice (Licence: NM DD3432) | |
| 122300000X Dentist (Licence: NM DD3432) | |
| Enumeration Date | 2005-10-10 |
| Last Update Date | 2013-03-01 |