| NPI | 1215240577 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NC 9097) |
| Additional Taxonomies | 122300000X Dentist (Licence: MS 3545-10) |
| Enumeration Date | 2010-07-15 |
| Last Update Date | 2012-05-09 |