| NPI | 1598957185 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WY 1302) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CO 10097) |
| Enumeration Date | 2007-08-16 |
| Last Update Date | 2012-12-10 |