| NPI | 1558406447 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NC 150542) |
| Additional Taxonomies | 122300000X Dentist (Licence: MO 2005015019) |
| Enumeration Date | 2007-02-20 |
| Last Update Date | 2016-08-08 |