| NPI | 1396962452 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: NM DD4210) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: AZ D3418) |
| Enumeration Date | 2007-04-19 |
| Last Update Date | 2015-03-11 |