| NPI | 1235115304 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223D0001X Dentist, Dental Public Health (Licence: MO 2001012903) |
| Additional Taxonomies | 122300000X Dentist (Licence: MO 2001012903) |
| Enumeration Date | 2005-12-20 |
| Last Update Date | 2012-11-06 |