| NPI | 1306157946 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NC 9091) |
| Additional Taxonomies | 122300000X Dentist (Licence: MO 2010018671) |
| 122300000X Dentist (Licence: SC 6950) | |
| Enumeration Date | 2010-06-29 |
| Last Update Date | 2011-10-24 |