| NPI | 1588079354 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MO 2017009433) |
| Additional Taxonomies | 122300000X Dentist (Licence: FL DN21510) |
| Enumeration Date | 2014-06-30 |
| Last Update Date | 2017-05-03 |