| NPI | 1487013546 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: AZ D9707) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: AZ D9707) |
| Enumeration Date | 2016-02-17 |
| Last Update Date | 2018-04-05 |