| NPI | 1265641450 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CT 4925) |
| Additional Taxonomies | 124Q00000X Dental Hygienist (Licence: CT 004938) |
| Enumeration Date | 2007-05-22 |
| Last Update Date | 2007-07-08 |