| NPI | 1346431798 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WV 3844) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MA 9475) |
| Enumeration Date | 2007-08-09 |
| Last Update Date | 2009-11-09 |