| NPI | 1306222427 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: OR 10425) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: IA DDS-09230) |
| Enumeration Date | 2015-07-31 |
| Last Update Date | 2016-11-17 |