| NPI | 1265423065 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: NM DD2599) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: CO 100964) |
| Enumeration Date | 2005-10-31 |
| Last Update Date | 2013-11-26 |