| NPI | 1356623995 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: IA 09501) |
| Additional Taxonomies | 122300000X Dentist (Licence: NV 6109) |
| 122300000X Dentist (Licence: NE 6998) | |
| Enumeration Date | 2011-09-09 |
| Last Update Date | 2019-04-11 |