| NPI | 1235391103 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: LA 6296) |
| Additional Taxonomies | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: MI 2901019754) |
| Enumeration Date | 2008-07-01 |
| Last Update Date | 2014-07-24 |