| NPI | 1205893310 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: AZ D6550) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 54631) |
| Enumeration Date | 2006-05-01 |
| Last Update Date | 2007-07-08 |