| NPI | 1235165325 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: OR MD19055) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: OR D6600) |
| Enumeration Date | 2006-06-23 |
| Last Update Date | 2012-01-17 |