| NPI | 1558461764 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CO 463) |
| Additional Taxonomies | 183500000X Pharmacist (Licence: CO 15445) |
| Enumeration Date | 2006-09-25 |
| Last Update Date | 2007-08-03 |