| NPI | 1477564722 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CO 00204184) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WI 3636WI) |
| Enumeration Date | 2006-08-11 |
| Last Update Date | 2021-09-19 |