| NPI | 1508130865 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: VA 0401415562) |
| Additional Taxonomies | 122300000X Dentist (Licence: SC DGD.8084GD) |
| Enumeration Date | 2012-03-05 |
| Last Update Date | 2020-05-28 |