| NPI | 1215360292 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: ID D-4690) |
| Additional Taxonomies | 122300000X Dentist (Licence: UT 8690227-9923) |
| Enumeration Date | 2013-08-14 |
| Last Update Date | 2019-05-06 |