| NPI | 1508978602 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: IA 08353) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: IA 08353) |
| Enumeration Date | 2006-08-31 |
| Last Update Date | 2008-04-30 |