| NPI | 1528583499 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: GA DN015798) |
| Additional Taxonomies | 122300000X Dentist (Licence: CO DEN.00203309) |
| Enumeration Date | 2017-08-11 |
| Last Update Date | 2019-09-23 |