| NPI | 1538422662 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223D0004X Dentist, Dentist Anesthesiologist Speciality (Licence: SC 8587) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS039125) |
| Enumeration Date | 2012-06-22 |
| Last Update Date | 2016-10-20 |