| NPI | 1215428602 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: CO DEN.00204138) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NM DD4881) |
| Enumeration Date | 2018-05-22 |
| Last Update Date | 2019-11-22 |