| NPI | 1518394964 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CO DEN.00202049) |
| Additional Taxonomies | 122300000X Dentist (Licence: NE 119) |
| Enumeration Date | 2013-10-01 |
| Last Update Date | 2016-06-03 |