| NPI | 1477614915 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: AZ 4729) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: CA 53352) |
| Enumeration Date | 2006-12-12 |
| Last Update Date | 2012-11-14 |