| NPI | 1366823528 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 31277) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: AZ D009265) |
| Enumeration Date | 2015-06-13 |
| Last Update Date | 2016-09-27 |