| NPI | 1215091137 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NV 4505) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: OK 5657) |
| Enumeration Date | 2006-12-22 |
| Last Update Date | 2015-11-10 |