| NPI | 1407102015 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: GA 8070) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: GA 8070) |
| Enumeration Date | 2012-08-01 |
| Last Update Date | 2012-08-01 |