| NPI | 1457767923 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: OR D10219) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: ID D4603) |
| Enumeration Date | 2014-07-06 |
| Last Update Date | 2015-07-06 |