| NPI | 1275939944 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223D0004X Dentist Dentist Anesthesiologist (Licence: PA DA020913A) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DSO20913L) |
| Enumeration Date | 2014-11-07 |
| Last Update Date | 2014-11-07 |