| NPI | 1265697387 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: SC 937) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WV 3833) |
| 1223G0001X Dentist, General Practice (Licence: SC 8879) | |
| Enumeration Date | 2008-07-29 |
| Last Update Date | 2018-03-17 |