| NPI | 1609131556 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: UT 8490181-9921) |
| Additional Taxonomies | 122300000X Dentist (Licence: FL DN 19856) |
| Enumeration Date | 2012-07-06 |
| Last Update Date | 2013-01-02 |