| NPI | 1467887984 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: PA DS039747) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: TX 32506) |
| Enumeration Date | 2013-09-04 |
| Last Update Date | 2017-02-09 |