| NPI | 1447325980 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MO 111178) |
| Additional Taxonomies | 122300000X Dentist (Licence: MO 014630) |
| Enumeration Date | 2006-11-21 |
| Last Update Date | 2018-02-15 |