| NPI | 1598076473 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: ID D4373) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: IA 08711) |
| Enumeration Date | 2010-06-25 |
| Last Update Date | 2018-03-17 |