| NPI | 1205845021 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: VA 0401005115) |
| Additional Taxonomies | 124Q00000X Dental Hygienist (Licence: VA 0402203393) |
| 126800000X Dental Assistant | |
| Enumeration Date | 2006-08-08 |
| Last Update Date | 2007-07-08 |