| NPI | 1508091018 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: RI DEN03144) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DE60096193) |
| 122300000X Dentist (Licence: CT 010880) | |
| Enumeration Date | 2009-05-28 |
| Last Update Date | 2013-09-28 |