| NPI | 1518053412 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: UT 9734638889221) |
| Additional Taxonomies | 122300000X Dentist (Licence: NV 4332) |
| 122300000X Dentist (Licence: CA 54973) | |
| Enumeration Date | 2006-10-05 |
| Last Update Date | 2007-07-08 |