| NPI | 1457880072 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: ND 2342) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: IA DDS-09420) |
| Enumeration Date | 2017-06-07 |
| Last Update Date | 2018-08-14 |