| NPI | 1538474572 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: TX 0026288) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: ID D-4309) |
| Enumeration Date | 2010-08-14 |
| Last Update Date | 2012-01-26 |