| NPI | 1215268784 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NC 09128) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NY 040113) |
| Enumeration Date | 2010-01-24 |
| Last Update Date | 2016-06-08 |