| NPI | 1336111319 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | |
| Primary Taxonomy | 1223E0200X Dentist Endodontics (Licence: NM DD2173) |
| Additional Taxonomies | 1223E0200X Dentist Endodontics (Licence: MO 2001012603) |
| Enumeration Date | 2006-02-03 |
| Last Update Date | 2007-07-08 |