| NPI | 1417211350 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: UT 8703919-9922) |
| Additional Taxonomies | 122300000X Dentist (Licence: MT 4140) |
| Enumeration Date | 2012-06-26 |
| Last Update Date | 2013-08-26 |