| NPI | 1548354012 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: CT 6363) |
| Additional Taxonomies | 122300000X Dentist (Licence: CT 6363) |
| Enumeration Date | 2006-10-02 |
| Last Update Date | 2014-12-16 |