| NPI | 1255408340 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WY 1033) |
| Additional Taxonomies | 1223P0300X Dentist, Periodontics (Licence: NE 6377) |
| Enumeration Date | 2006-11-30 |
| Last Update Date | 2014-12-09 |