| NPI | 1407170293 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: TX 27058) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS037269) |
| Enumeration Date | 2010-03-23 |
| Last Update Date | 2012-10-24 |