| NPI | 1295889020 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: UT 7946678) |
| Additional Taxonomies | 122300000X Dentist (Licence: NV 2567) |
| 1223G0001X Dentist General Practice (Licence: NV 2567) | |
| Enumeration Date | 2007-01-22 |
| Last Update Date | 2019-05-01 |