| NPI | 1497870109 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NC 10514) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: FL DN14789) |
| Enumeration Date | 2007-03-20 |
| Last Update Date | 2017-01-27 |