| NPI | 1336134048 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: VA 0401412031) |
| Additional Taxonomies | 122300000X Dentist (Licence: DC DEN1000421) |
| 122300000X Dentist (Licence: NJ 22D102229700) | |
| 122300000X Dentist (Licence: NC 7973) | |
| Enumeration Date | 2005-09-19 |
| Last Update Date | 2016-08-18 |