| NPI | 1508901406 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MO 2008033774) |
| Additional Taxonomies | 122300000X Dentist (Licence: UT 5546679-9922) |
| 122300000X Dentist (Licence: CO 6506) | |
| Enumeration Date | 2007-02-20 |
| Last Update Date | 2012-12-10 |