| NPI | 1265548432 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: UT 337850) |
| Additional Taxonomies | 122300000X Dentist (Licence: OR D8578) |
| 1223G0001X Dentist, General Practice (Licence: OR D8578) | |
| Enumeration Date | 2006-08-21 |
| Last Update Date | 2020-02-24 |