| NPI | 1457752172 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: GA DN015143.) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS040187) |
| Enumeration Date | 2014-09-12 |
| Last Update Date | 2016-05-16 |