| NPI | 1235211129 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: AL DO654) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: AL 4622) |
| Enumeration Date | 2006-10-19 |
| Last Update Date | 2011-08-24 |