| NPI | 1376758318 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: GA DN014067) |
| Additional Taxonomies | 106H00000X Marriage & Family Therapist (Licence: GA MFT001004) |
| 106H00000X Marriage & Family Therapist (Licence: UT 4929966-3902) | |
| Enumeration Date | 2007-05-12 |
| Last Update Date | 2010-05-28 |