| NPI | 1275829160 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: CO 00204502) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: OK 6297) |
| Enumeration Date | 2011-06-20 |
| Last Update Date | 2021-10-04 |