| NPI | 1568734184 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: PR 1466) |
| Additional Taxonomies | 1223P0300X Dentist Periodontics (Licence: MD 1466) |
| 1223P0700X Dentist Prosthodontics (Licence: MD 1466) | |
| Enumeration Date | 2012-01-27 |
| Last Update Date | 2012-01-27 |