| NPI | 1427466903 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: WY 1490) |
| Additional Taxonomies | 122300000X Dentist (Licence: NE 7182) |
| Enumeration Date | 2014-07-28 |
| Last Update Date | 2018-03-29 |