| NPI | 1336128123 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MD 7480) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NC 9256) |
| Enumeration Date | 2006-01-11 |
| Last Update Date | 2012-02-02 |