| NPI | 1245348960 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MS 2882-95) |
| Additional Taxonomies | 122300000X Dentist (Licence: AL 5389 C) |
| 1223P0300X Dentist, Periodontics (Licence: MS PER-323-98) | |
| 1223P0300X Dentist, Periodontics (Licence: AL 5389 C) | |
| Enumeration Date | 2006-08-25 |
| Last Update Date | 2007-07-08 |