| NPI | 1316201536 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MD 16183) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA 0401413856) |
| Enumeration Date | 2012-07-03 |
| Last Update Date | 2016-08-25 |