| NPI | 1508891854 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223D0004X Dentist, Dentist Anesthesiologist Speciality (Licence: PA DS020309L) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS020309L) |
| 122300000X Dentist (Licence: TX 13252) | |
| 122300000X Dentist (Licence: OH 30022183) | |
| 122300000X Dentist (Licence: WV 3657) | |
| Enumeration Date | 2006-07-12 |
| Last Update Date | 2013-06-04 |