| NPI | 1336119528 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MO 2010010741) |
| Additional Taxonomies | 122300000X Dentist (Licence: IL 019-026178) |
| 1223E0200X Dentist, Endodontics (Licence: VA 0401413366) | |
| Enumeration Date | 2006-01-23 |
| Last Update Date | 2011-12-09 |