| NPI | 1316113822 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: AZ 2121) |
| Additional Taxonomies | 1223P0106X Dentist, Oral and Maxillofacial Pathology (Licence: AZ 2121) |
| Enumeration Date | 2008-05-05 |
| Last Update Date | 2008-05-08 |