| NPI | 1487093258 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: IA DDS-09131) |
| Additional Taxonomies | 122300000X Dentist (Licence: WI 7114-15) |
| Enumeration Date | 2013-06-14 |
| Last Update Date | 2014-11-06 |