| NPI | 1568529345 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MD 10472) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NV 7185) |
| Enumeration Date | 2007-01-02 |
| Last Update Date | 2019-07-31 |