| NPI | 1295055895 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: CT 010564) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA 1855397) |
| Enumeration Date | 2010-06-04 |
| Last Update Date | 2014-01-30 |