| NPI | 1306031539 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CO 10185) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: UT 5341183-9922) |
| Enumeration Date | 2007-09-11 |
| Last Update Date | 2018-06-22 |