| NPI | 1306991229 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MI 2901010302) |
| Additional Taxonomies | 122300000X Dentist (Licence: WI s001162015) |
| Enumeration Date | 2007-01-23 |
| Last Update Date | 2007-07-08 |