| NPI | 1326181579 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WY WY1538) |
| Additional Taxonomies | 122300000X Dentist (Licence: OR D7768) |
| 1223G0001X Dentist, General Practice (Licence: WY 1538) | |
| 1223G0001X Dentist, General Practice (Licence: MT 4200) | |
| Enumeration Date | 2007-02-15 |
| Last Update Date | 2021-06-03 |