| NPI | 1588747737 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist Periodontics (Licence: MS 2649) |
| Additional Taxonomies | 1223P0300X Dentist Periodontics (Licence: GA PER24293) |
| Enumeration Date | 2006-10-23 |
| Last Update Date | 2007-07-08 |