| NPI | 1295060655 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: NC 10663) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: FL 24771) |
| Enumeration Date | 2009-10-02 |
| Last Update Date | 2017-11-21 |