| NPI | 1609085133 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA 25545) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: AK 469) |
| 1223G0001X Dentist, General Practice (Licence: WA DE00006955) | |
| 1223G0001X Dentist, General Practice (Licence: HI DT1354) | |
| Enumeration Date | 2007-05-22 |
| Last Update Date | 2007-07-08 |