| NPI | 1265593107 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: WI 6211-15) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MO 2005037623) |
| Enumeration Date | 2006-12-13 |
| Last Update Date | 2019-12-30 |