| NPI | 1356396972 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: TN DS2836) |
| Additional Taxonomies | 122300000X Dentist (Licence: NC 4159) |
| 122300000X Dentist (Licence: KY 4533) | |
| Enumeration Date | 2006-05-23 |
| Last Update Date | 2007-07-08 |