| NPI | 1558499335 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: AZ D7144) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 55127) |
| Enumeration Date | 2007-03-01 |
| Last Update Date | 2012-05-22 |