| NPI | 1548518574 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: GA DN014619) |
| Additional Taxonomies | 122300000X Dentist (Licence: MS 3540-10) |
| Enumeration Date | 2012-08-23 |
| Last Update Date | 2014-10-23 |