| NPI | 1508980764 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: VA 0401413142) |
| Additional Taxonomies | 122300000X Dentist (Licence: NC 8666) |
| 1223G0001X Dentist General Practice (Licence: FL DN17137) | |
| Enumeration Date | 2007-03-16 |
| Last Update Date | 2014-06-13 |