| NPI | 1306150768 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: OR D9455) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA 0401412929) |
| Enumeration Date | 2010-07-27 |
| Last Update Date | 2016-09-07 |