| NPI | 1396008132 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: IA DDS-09259) |
| Additional Taxonomies | 122300000X Dentist (Licence: MO 2012018222) |
| Enumeration Date | 2012-06-18 |
| Last Update Date | 2016-01-04 |