| NPI | 1366879728 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: CO 00202761) |
| Additional Taxonomies | 122300000X Dentist (Licence: IL 019029653) |
| Enumeration Date | 2013-10-01 |
| Last Update Date | 2016-09-02 |