| NPI | 1417245242 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: NM DD3537) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: CA 61410) |
| Enumeration Date | 2011-07-13 |
| Last Update Date | 2012-10-02 |