| NPI | 1558661579 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: DC DEN1001590) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: VA 0401412951) |
| Enumeration Date | 2010-10-25 |
| Last Update Date | 2016-07-20 |