| NPI | 1306903919 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: NM DD1832) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: PA DS016448) |
| Enumeration Date | 2007-01-02 |
| Last Update Date | 2008-01-23 |