| NPI | 1578655916 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: AZ D07954) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WV 3701) |
| Enumeration Date | 2006-09-29 |
| Last Update Date | 2017-12-29 |