| NPI | 1467688861 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE 60504242) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 055127) |
| Enumeration Date | 2009-06-01 |
| Last Update Date | 2014-11-19 |