| NPI | 1316351851 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: VA 0401415130) |
| Additional Taxonomies | 122300000X Dentist (Licence: FL DN20689) |
| Enumeration Date | 2014-06-12 |
| Last Update Date | 2016-04-07 |