| NPI | 1568611374 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist Periodontics (Licence: SD D0968) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: SC 4492) |
| Enumeration Date | 2008-09-17 |
| Last Update Date | 2013-04-17 |