| NPI | 1356546857 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NC 8459) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MS 3413-07) |
| 1223D0001X Dentist, Dental Public Health (Licence: NC 8459) | |
| Enumeration Date | 2007-06-15 |
| Last Update Date | 2011-09-12 |