| NPI | 1548278807 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CO DEN-10163) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MI 11206) |
| Enumeration Date | 2006-08-03 |
| Last Update Date | 2011-08-11 |