| NPI | 1275924151 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CO DEN.00203407) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DN-001987) |
| 122300000X Dentist (Licence: PA DS-039789) | |
| 122300000X Dentist (Licence: VA 0401414721) | |
| Enumeration Date | 2015-02-12 |
| Last Update Date | 2018-01-08 |