| NPI | 1508065806 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: PA DS039923) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: TX 23307) |
| Enumeration Date | 2007-07-16 |
| Last Update Date | 2021-03-04 |