| NPI | 1588676605 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WV 3712) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS037470) |
| Enumeration Date | 2006-08-13 |
| Last Update Date | 2021-10-26 |