| NPI | 1558423293 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 23087) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: GA DN012199) |
| 1223G0001X Dentist, General Practice (Licence: VA 0401410694) | |
| 1223G0001X Dentist, General Practice (Licence: SC 3774) | |
| Enumeration Date | 2006-12-15 |
| Last Update Date | 2010-06-09 |