| NPI | 1356717987 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MO 2018011706) |
| Additional Taxonomies | 122300000X Dentist (Licence: OR D10311) |
| Enumeration Date | 2015-08-18 |
| Last Update Date | 2018-04-13 |