| NPI | 1457525263 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CO 10054) |
| Additional Taxonomies | 122300000X Dentist (Licence: NM DD3069) |
| Enumeration Date | 2008-04-14 |
| Last Update Date | 2022-02-04 |