| NPI | 1558641589 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: AZ D008280) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CA 60614) |
| Enumeration Date | 2011-08-22 |
| Last Update Date | 2011-08-22 |