| NPI | 1275649311 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WV 3478) |
| Additional Taxonomies | 1223P0300X Dentist Periodontics (Licence: WV 23) |
| Enumeration Date | 2006-08-22 |
| Last Update Date | 2007-07-08 |