| NPI | 1417477241 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WY 1473) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WY 1473) |
| Enumeration Date | 2017-06-22 |
| Last Update Date | 2017-06-22 |