| NPI | 1316169485 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MO 2020005797) |
| Additional Taxonomies | 122300000X Dentist (Licence: CO 9893) |
| 122300000X Dentist (Licence: NE 6658) | |
| 122300000X Dentist (Licence: MO 2006015458) | |
| Enumeration Date | 2007-05-02 |
| Last Update Date | 2020-04-27 |