| NPI | 1396855466 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: PR 972) |
| Additional Taxonomies | 122300000X Dentist (Licence: PR 972) |
| Enumeration Date | 2006-08-30 |
| Last Update Date | 2016-01-20 |