| NPI | 1518122795 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: WI 5000407-015) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WI 5000407-015) |
| Enumeration Date | 2008-07-27 |
| Last Update Date | 2008-07-27 |