| NPI | 1275678609 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: DC DEN1001770) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MD 12582) |
| Enumeration Date | 2007-02-21 |
| Last Update Date | 2021-04-16 |