| NPI | 1417976259 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: VA 0401413155) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: PA ds029416-L) |
| Enumeration Date | 2006-07-19 |
| Last Update Date | 2016-02-26 |