| NPI | 1568588580 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: FL DN16721) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: PA DS036320) |
| Enumeration Date | 2007-03-21 |
| Last Update Date | 2011-07-26 |