| NPI | 1508980772 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: NC 0064) |
| Additional Taxonomies | 1223P0300X Dentist, Periodontics (Licence: TX 19014) |
| Enumeration Date | 2007-03-16 |
| Last Update Date | 2007-07-08 |