| NPI | 1316199268 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CO 7583) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 15836) |
| Enumeration Date | 2008-10-22 |
| Last Update Date | 2015-11-05 |