| NPI | 1588658470 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0700X Dentist, Prosthodontics (Licence: OK Prosthodontics 30) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 18073) |
| Enumeration Date | 2005-09-07 |
| Last Update Date | 2007-07-08 |