| NPI | 1467680504 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: WI 1001793) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 25283) |
| 122300000X Dentist (Licence: IL 019027961) | |
| 122300000X Dentist (Licence: NM DD3585) | |
| Enumeration Date | 2009-06-28 |
| Last Update Date | 2021-06-16 |