| NPI | 1285861104 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: AR 3704) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 26320) |
| Enumeration Date | 2009-06-18 |
| Last Update Date | 2015-01-26 |