| NPI | 1508067836 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: KS 60483) |
| Additional Taxonomies | 122300000X Dentist (Licence: MO 2008012647) |
| Enumeration Date | 2007-05-31 |
| Last Update Date | 2011-02-15 |