| NPI | 1265862544 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CO 202684) |
| Additional Taxonomies | 122300000X Dentist (Licence: MO 2013030955) |
| Enumeration Date | 2013-11-22 |
| Last Update Date | 2018-03-17 |