| NPI | 1508897992 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: PR 1489) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 27916) |
| 1223G0001X Dentist, General Practice (Licence: IL 019.028957) | |
| Enumeration Date | 2006-07-05 |
| Last Update Date | 2014-06-13 |