| NPI | 1306178132 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NM DD3407) |
| Additional Taxonomies | 122300000X Dentist (Licence: CO 10112) |
| Enumeration Date | 2010-02-04 |
| Last Update Date | 2015-12-13 |