| NPI | 1285814772 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: UT 65942819921) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: UT 65942819921) |
| Enumeration Date | 2007-11-13 |
| Last Update Date | 2007-11-13 |