| NPI | 1356667786 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: PR 17869) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: PR 17869) |
| Enumeration Date | 2010-04-09 |
| Last Update Date | 2019-08-06 |