| NPI | 1578777991 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: FL 9768) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WV 3654) |
| 1223G0001X Dentist, General Practice (Licence: NY 051845) | |
| Enumeration Date | 2007-05-09 |
| Last Update Date | 2011-09-01 |