| NPI | 1316147218 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: TX 27248) |
| Additional Taxonomies | 122300000X Dentist (Licence: OK 6091) |
| 1223G0001X Dentist General Practice (Licence: MO 2007018212) | |
| Enumeration Date | 2007-07-19 |
| Last Update Date | 2011-12-14 |