| NPI | 1235382557 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: OR d9201) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: OR 9201) |
| Enumeration Date | 2008-10-30 |
| Last Update Date | 2018-01-31 |