| NPI | 1255489811 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: LA 5338) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: FL DN17475) |
| Enumeration Date | 2007-01-08 |
| Last Update Date | 2007-07-08 |