| NPI | 1255350369 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: LA 3515) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MS 3268-03) |
| 1223P0221X Dentist, Pediatric Dentistry (Licence: LA PEDO3703) | |
| Enumeration Date | 2006-07-19 |
| Last Update Date | 2013-07-16 |